- Email: [email protected]
A HOSPITAL PLAN FOR 1966
662 bronchial asthma are characterised by transient periods of unsteady which must result in fluctuations in the exchange ratio. For this reason, unless it can be shown in a given patient that ventilation is being seriously depressed by oxygen, we would consider the use of a ventimask contraindicated, and would recommend the use of high inspired-oxygen concentrations delivered by conventional means. (2) When oxygen does not significantly depress ventilation, its administration in high concentration may prolong life by the prevention of fatal hypoxia while high alveolar carbon-dioxide tensions and extreme acidsemia are developing as a consequence of the underlying respiratory failure. The reason why patients in respiratory failure do not develop blood-levels of PCO, much above 80 mm. or values of pH below 7-2 when breathing air is simply that a higher PCO, would compel an alveolar oxygen tension so low as to be fatal. The patients with asthma reported by us did not have ventilatory depression from oxygen therapy. Patient 1, for example, while receiving high inspired-oxygen concentrations, continued to exert maximum ventilatory effort against an extraordinarily high airway resistance until bronchospasm was relieved by the correction of acidaemia with bicarbonate. Indeed, if he had not received a high inspired-oxygen concentration his PCO, would not have been so high nor his pH so low, because he would long since have been dead from hypoxia. In his case, oxygen delivered by a ventimask would probably not have been adequate, because of frequent transient periods of unsteady state and an abnormally high A-a oxygen state
gradient.
important to recognise the potential danger of ventilatory depression by high inspired-oxygen concentrations in patients with chronic pulmonary disease and to use " controlled " oxygen therapy under appropriate circumstances. However, it has not, as far as we know, been previously pointed out that there are potential dangers in the use of this technique in patients with rapidly fluctuating levels of respiratory function; nor is it apparently recognised that when ventilation is not depressed by high inspired-oxygen concentrations extreme respiratory acidosis may be allowed (not caused) by such therapy. JOHN C. MITHOEFER It is
I
Cardio-Pulmonary Laboratory, Mary Imogene Bassett Hospital, Cooperstown, New York.
The
RICHARD H. RUNSER MONROE S. KARETZKY.
BACTERÆMIC SHOCK
SIR,-Mr. Singh (March 5) reports an interesting case of bacterxmic shock due to a gram-positive coccus. In his discussion he refers to endotoxins. Although the formerly rigid concept of exotoxin and endotoxin is undergoing modification, the term endotoxin means the toxic lipopolysaccharide constituent of gram-negative bacterial cell walls. Gram-positive cocci do not possess this constituent: therefore the reported case, although an example of bacter2emic shock, is not one of endotoxin shock as is implied. There is evidence that gram-positive organisms can produce endotoxin-like substances,’and it is widely recognised that septicaemia with gram-positive cocci can cause a shock syndrome, but most cases of bacterxmic shock are due to gramnegative bacilli and their endotoxins. This has been confirmed by many large series of cases,34 and in my own series being collected at present I have not yet come across a case due to a
gram-positive organism. Mr. Singh states: " Bacterxmic
shock is caused by endotoxins released when bacteria enter the blood-stream in large numbers." This need not be so. In many conditions endotoxaEmia may cause shock, although the blood-stream is sterile. A good example of this is the endotoxin shock which may arise from fsecal peritonitis, when endotoxins are absorbed from the peritoneum long before bacterxmia develops. Socalled " catheter fever " after urethral catheterisation is another manifestation of endotoxaemia not necessarily accompanied by bacterxmia. As to treatment, the administration of blood or plasma is of doubtful value in the absence of hypovolsemia. The role of 1. 2. 3. 4.
...
Stetson, C. A.J. exp. Med. 1956, 104, 921. Skinner, D. G., Hayes, M. A. Ann. Surg. 1965, 162, 161. Weil, M. H. Ann. intern. Med. 1964, 60, 384. Martin, W. J., McHenry, M. C. Med. Clins N. Am. 1962, 46,
1073.
antibiotics is undisputed, but an attempt to alleviate the vascular effects of endotoxin is also of prime importance-corticosteroids, adrenergic inhibitors, and low-molecular-weight dextran help to do this. Department of Surgery, Royal Infirmary, Glasgow, C.4.
CHARLES J. WRIGHT.
A HOSPITAL PLAN FOR 1966
SirsConsultant " (Feb. 26) has not exaggerated. All over the country, pedestrian plans limp forward for new hospitals to sprawl over vast areas of land: and Northwick Park1 may be regarded as a luxurious prototype. Only those such as the attractive new Royal Free Hospital,2 unfortunate (official terminology) in having a cramped site ", are likely to Consultant " has also graphically portrayed the escape. hazards and the maintenance cost of hospitals where distances between departments are enormous. No doubt he will be told he was adequately " consulted ", but it is also apparent that he was ignored. At Northwick Park, by estimate from the scale,3 the maternity block is a good 600 yards from the residential area and a handy 400 yards from the operating-theatres, where presumably the anaesthetists and obstetricians will spend some of their time in gynaecological pursuits. The siting of the X-ray department some 200 yards along the street " from the main wards can only be regarded as an effort to combat unemployment in the computer age, while the same goes for physical medicine, whose clientele and the luckless porters are more likely to be in need of the services of the recovery unit than the gymnasium. One would have thought after twenty-five years of virtual standstill in hospital building in this country an attempt would have been made to repair the gaps in our expertise by freer use of experience or the employment of hospital architects from the Continent or the U.S.A. where concentration of design continues to have high priority because of the absolute need to keep maintenance costs at a minimum. Gordon Friesenhas estimated these per annum as 40% of the capital cost of a hospital in the U.S.A.-70% of the maintenance costs going on salaries and wages (60% in U.K.). The adoption of a conveyorbelt system for everything possible in a number of hospitals in the U.S.A., Friesen asserted, has resulted in savings in running costs that will repay the capital of a hospital in twenty years. If British planners are right in advocating the extended layout, in the manner of the urban precinct, as at Northwick Park, "
"
"
"
"
then the rest of the world has been wrong. Should we not insist on an adequate pilot study before committing so much of our new hospital building to what is probably a costly heresy ? Administrator " (Feb. 5), by speaking out on the present unhappy situation, has performed a public service. Most people will agree that there must be standardisation, either of whole hospital units, or better still of large components such as wards, operating-theatres, and ancillary departments, so that there will be choice, and if errors are made they will not be repeated everywhere. The programme should be handed to our great constructional engineering firms whose offers to help have hitherto been cold-shouldered. What cannot be accepted is that inferior quality is inseparable from standardisation, or that this country cannot afford to do better than lay a burden of mediocrity on future generations. The root cause of present deficiencies in planning, however, lies in the ponderous financial and administrative structure of the N.H.S. about which there is a myth of immutability. Much that will make the new hospitals impossible to run arises from petty capital allocations spread over many years, necessitating multiple phasing. This has led defenders of the extended hospital layout to make a virtue out of necessity. It should be accepted immediately that it is better to complete five compact hospitals over five years if they are economic "
1. 2. 3. 4.
See Lancet, Feb. 26, 1966, p. 477. Br. med. J. Jan. 29, 1966, p. 289. Br. med. J. Feb. 26, 1966, p. 535. See Lancet, 1961, i, 1275.
663 then to mess about phasing ten extended-design hospitals of similar size over ten years if they are to be maintenance liabilities. If this means spending more on interim developments it should be faced cheerfully because it is cheaper in the end; but the distress and back-pedalling of politicians and vested interest will be horrible to behold-which underlines my belief that the N.H.S. should be run as a National to run,
Corporation.
J. W. PAULLEY. SIR,-I write in support of the point of view of
"
Consultant". Much of what he has written is corroborated by my own experience at this hospital. Baguley Hospital, now a thoracic unit, was originally an infectious-diseases unit. Two of the ward blocks (B4 and B5; are built, on the old " fevers hospital " pattern, on two floors with an external staircase. Each of these blocks, containing roughly 30 beds, is run as a ward on two floors. In order tc increase the bed-occupancy of the upper floors, bed-lifts were requested. In 1963 the regional hospital board (R.H.B.) agreed that lifts should be installed, and offered chair-lifts or stretcherlifts. These were refused by the medical staff, and in 1964 several letters were written to the group secretary of the hospital management committee (H.M.C.) advising that bed-lifts were
necessary.
In May, 1965, the hospital medical staff committee (m.s.c..’ learned from a casual source that a decision had been reached to install stretcher-lifts during the current financial year. Immediate representations were made, urging that bed-lifts were necessary: early in July assurances were sought and obtained from the hospital secretary and from the house committee that any lifts installed would be capable of accommodating a bed. On July 30, 1965, however, at a meeting of the South Manchester H.M.c., on which no member of the medical stafl of this hospital sits, it was decided to accept the R.H.B.’S offer to install stretcher-lifts, since the board had made it clear that considerations of cost precluded the provision of bed-lifts. Minutes of H.M.C. meetings are sent to the secretaries of hospital M.s.c.s, but the minutes of this particular meeting were not sent until Oct. 8, 1965, and by the time their content was appreciated the contract for the lifts had already been given, and the contractors were ready to start. After representations by the M.s.c., the South Manchester H.M.C. agreed that stretcher-lifts would be unsatisfactory, and made representations to the regional board, requesting that plans for the lifts should be modified so that the lifts could accommodate a bed. The R.H.B. rejected these proposals, and indicated that the alternatives lay between having stretcherlifts and having no lifts at all. Faced with these alternatives the H.M.c., despite the appeals of the M.s.c., agreed to accept stretcher-lifts. The M.s.c., however, was unanimous in its opinion that the installation of stretcher-lifts or trolley-lifts would not increase materially the usage of the upstairs wards for medical and surgical emergencies, and for seriously ill patients. In its opinion the only way to obtain maximum bed-occupancy was to provide a lift or lifts capable of taking a bed and an attendant. It appreciated the help that it had received from the R.H.B. and the H.M.c., and was grateful that they should be willing to install lifts which were so badly needed in these wards. But the M.s.c. was unanimous that rather than have installed unsatisfactory lifts, which would preclude the future installation of bed-lifts, it would prefer to do without until such time as an adequate lift or lifts could be provided. Its reasons for this decision were as follows: reaching 1. The transfer of patients from stretchers or beds to trolleys in order to transport them upstairs, where they would again be transferred to a bed, would place a heavy burden on the nursing staff, and would cause discomfort and perhaps danger to patients. 2. Transfer of patients in this way between floors would greatly increase the amount of bed-making and use of bed-linen. 3. In an emergency it is vital to be able to move a patient rapidly between floors-e.g., in the event of sudden acute illness in a patient
upstairs.
4. Wards B4 and B5 each comprise a ward unit on two floors. In busy ward unit it is essential to maintain maximum flexibility of movement of patients. This could not be provided by trolley-lifts. 5. With the development of the cardiopulmonary unit in the new Wythenshawe Hospital, there will be a shortage of cardiothoracic beds, and since wards B4 and B5 are closest to the new unit they will be the most suitable to deal with acutely ill patients from that unit. a
deeply resentful of the fact that at no time hospital medical or nursing staffs consulted while these lifts were under consideration. They appealed against the decision to install stretcher-lifts to the H.M.C., to the R.H.B., and finally to the Minister of Health. The appeals failed. This was hardly surprising, but what rankles is that in rejecting the appeals each of the referees expressed satisfaction that the normal machinery for consultation had been available to all parties in the dispute, that the H.M.C. and R.H.B. had used this machinery, but that the M.s.c. had failed to avail itself of the proper consultative procedures. It is difficult to reconcile this opinion with the known facts of The
was
M.s.c. was
any member of the
the case, but there is no doubt that the records will show that consultation took place. Before this dispute is relegated to the dusty files of oblivion, one should perhaps ponder on the meaning of the word consultation ". To consult is to seek advice. In the present context consultation means discussion of a situation with interchange of ideas in order to resolve any difficulties on differences of opinion which may exist. It does not mean, as in this instance, that a decision is taken to provide an amenity without discussion with the users, whose opinions and advice are ignored. I believe that in the National Health Service, as in every walk of life, consultation is essential. But consultation must be made an active process and not remain just an empty word. "
Baguley Hospital, Wythenshawe, Manchester, 23.
T. M. WILSON.
CENTRAL STERILE SUPPLY SiR,ŅWhile any serious attempt to produce a paper specifically designed as an efficient bacterial barrier to meet the needs of both central sterile supply department (c.s.s.D.) and industry is to be applauded, too great stress on the inclusion of antibacterial agents as suggested by Mr. Fellows (Jan. 29) might well be misleading. The paper industry has for many years included antibacterial and antifungal agents during the actual manufacture of paper and board likely to be used or stored under conditions which would render them susceptible to spoilage. Substances such as o-phenylphenol (in glassine-type papers) and its water-soluble sodium salt, and particularly quaternary ammonium compounds, have been used. On the question of the maintenance of sterility, what good one wonders is a paper with an antifungal or antibacterial agent incorporated in it, if pinholes allow organisms to pass through unimpeded, and if organisms that come in contact with the paper are not moist ? On the latter point, we see no reason to doubt the validity of the work carried out at the Cross-Infection Reference Laboratory, Colindale,l on tests of self-disinfecting surfaces, which indicated that only surfaces which evolved formaldehyde showed any activity against dust-borne bacteria. The letter2 which prompted Mr. Fellows to write deserves some favourable comment, for it puts simply and concisely the various aspects of packaging for sterilised goods which are of prime importance to the hospital c.s.s.D. Particularly interesting were its comments on the use of paper. In practice pinhole-free paper, of even consistency, which does not allow the passage of bacteria in the dry or wet state, is ideal, and to this end a considerable amount of work has been carried out in this laboratory since the Nuffield report3 was published in 1958. In 1961 Hunter et al.4 demonstrated that papers of a certain 1. Kingston, D., Noble, W. C. J. Hyg., Camb. 1964, 62, 519. 2. Allen, S. M., et al. Lancet, 1965, ii, 1343. 3. Sterilisation Practice in Six Hospitals. Nuffield Provincial Hospitals Trust, London, 1958. 4. Hunter, C. L. F., Harbord, P. E., Riddett, D. J. in Symposium on Sterilisation of Surgical Materials. London, 1961.
gradient.
important to recognise the potential danger of ventilatory depression by high inspired-oxygen concentrations in patients with chronic pulmonary disease and to use " controlled " oxygen therapy under appropriate circumstances. However, it has not, as far as we know, been previously pointed out that there are potential dangers in the use of this technique in patients with rapidly fluctuating levels of respiratory function; nor is it apparently recognised that when ventilation is not depressed by high inspired-oxygen concentrations extreme respiratory acidosis may be allowed (not caused) by such therapy. JOHN C. MITHOEFER It is
I
Cardio-Pulmonary Laboratory, Mary Imogene Bassett Hospital, Cooperstown, New York.
The
RICHARD H. RUNSER MONROE S. KARETZKY.
BACTERÆMIC SHOCK
SIR,-Mr. Singh (March 5) reports an interesting case of bacterxmic shock due to a gram-positive coccus. In his discussion he refers to endotoxins. Although the formerly rigid concept of exotoxin and endotoxin is undergoing modification, the term endotoxin means the toxic lipopolysaccharide constituent of gram-negative bacterial cell walls. Gram-positive cocci do not possess this constituent: therefore the reported case, although an example of bacter2emic shock, is not one of endotoxin shock as is implied. There is evidence that gram-positive organisms can produce endotoxin-like substances,’and it is widely recognised that septicaemia with gram-positive cocci can cause a shock syndrome, but most cases of bacterxmic shock are due to gramnegative bacilli and their endotoxins. This has been confirmed by many large series of cases,34 and in my own series being collected at present I have not yet come across a case due to a
gram-positive organism. Mr. Singh states: " Bacterxmic
shock is caused by endotoxins released when bacteria enter the blood-stream in large numbers." This need not be so. In many conditions endotoxaEmia may cause shock, although the blood-stream is sterile. A good example of this is the endotoxin shock which may arise from fsecal peritonitis, when endotoxins are absorbed from the peritoneum long before bacterxmia develops. Socalled " catheter fever " after urethral catheterisation is another manifestation of endotoxaemia not necessarily accompanied by bacterxmia. As to treatment, the administration of blood or plasma is of doubtful value in the absence of hypovolsemia. The role of 1. 2. 3. 4.
...
Stetson, C. A.J. exp. Med. 1956, 104, 921. Skinner, D. G., Hayes, M. A. Ann. Surg. 1965, 162, 161. Weil, M. H. Ann. intern. Med. 1964, 60, 384. Martin, W. J., McHenry, M. C. Med. Clins N. Am. 1962, 46,
1073.
antibiotics is undisputed, but an attempt to alleviate the vascular effects of endotoxin is also of prime importance-corticosteroids, adrenergic inhibitors, and low-molecular-weight dextran help to do this. Department of Surgery, Royal Infirmary, Glasgow, C.4.
CHARLES J. WRIGHT.
A HOSPITAL PLAN FOR 1966
SirsConsultant " (Feb. 26) has not exaggerated. All over the country, pedestrian plans limp forward for new hospitals to sprawl over vast areas of land: and Northwick Park1 may be regarded as a luxurious prototype. Only those such as the attractive new Royal Free Hospital,2 unfortunate (official terminology) in having a cramped site ", are likely to Consultant " has also graphically portrayed the escape. hazards and the maintenance cost of hospitals where distances between departments are enormous. No doubt he will be told he was adequately " consulted ", but it is also apparent that he was ignored. At Northwick Park, by estimate from the scale,3 the maternity block is a good 600 yards from the residential area and a handy 400 yards from the operating-theatres, where presumably the anaesthetists and obstetricians will spend some of their time in gynaecological pursuits. The siting of the X-ray department some 200 yards along the street " from the main wards can only be regarded as an effort to combat unemployment in the computer age, while the same goes for physical medicine, whose clientele and the luckless porters are more likely to be in need of the services of the recovery unit than the gymnasium. One would have thought after twenty-five years of virtual standstill in hospital building in this country an attempt would have been made to repair the gaps in our expertise by freer use of experience or the employment of hospital architects from the Continent or the U.S.A. where concentration of design continues to have high priority because of the absolute need to keep maintenance costs at a minimum. Gordon Friesenhas estimated these per annum as 40% of the capital cost of a hospital in the U.S.A.-70% of the maintenance costs going on salaries and wages (60% in U.K.). The adoption of a conveyorbelt system for everything possible in a number of hospitals in the U.S.A., Friesen asserted, has resulted in savings in running costs that will repay the capital of a hospital in twenty years. If British planners are right in advocating the extended layout, in the manner of the urban precinct, as at Northwick Park, "
"
"
"
"
then the rest of the world has been wrong. Should we not insist on an adequate pilot study before committing so much of our new hospital building to what is probably a costly heresy ? Administrator " (Feb. 5), by speaking out on the present unhappy situation, has performed a public service. Most people will agree that there must be standardisation, either of whole hospital units, or better still of large components such as wards, operating-theatres, and ancillary departments, so that there will be choice, and if errors are made they will not be repeated everywhere. The programme should be handed to our great constructional engineering firms whose offers to help have hitherto been cold-shouldered. What cannot be accepted is that inferior quality is inseparable from standardisation, or that this country cannot afford to do better than lay a burden of mediocrity on future generations. The root cause of present deficiencies in planning, however, lies in the ponderous financial and administrative structure of the N.H.S. about which there is a myth of immutability. Much that will make the new hospitals impossible to run arises from petty capital allocations spread over many years, necessitating multiple phasing. This has led defenders of the extended hospital layout to make a virtue out of necessity. It should be accepted immediately that it is better to complete five compact hospitals over five years if they are economic "
1. 2. 3. 4.
See Lancet, Feb. 26, 1966, p. 477. Br. med. J. Jan. 29, 1966, p. 289. Br. med. J. Feb. 26, 1966, p. 535. See Lancet, 1961, i, 1275.
663 then to mess about phasing ten extended-design hospitals of similar size over ten years if they are to be maintenance liabilities. If this means spending more on interim developments it should be faced cheerfully because it is cheaper in the end; but the distress and back-pedalling of politicians and vested interest will be horrible to behold-which underlines my belief that the N.H.S. should be run as a National to run,
Corporation.
J. W. PAULLEY. SIR,-I write in support of the point of view of
"
Consultant". Much of what he has written is corroborated by my own experience at this hospital. Baguley Hospital, now a thoracic unit, was originally an infectious-diseases unit. Two of the ward blocks (B4 and B5; are built, on the old " fevers hospital " pattern, on two floors with an external staircase. Each of these blocks, containing roughly 30 beds, is run as a ward on two floors. In order tc increase the bed-occupancy of the upper floors, bed-lifts were requested. In 1963 the regional hospital board (R.H.B.) agreed that lifts should be installed, and offered chair-lifts or stretcherlifts. These were refused by the medical staff, and in 1964 several letters were written to the group secretary of the hospital management committee (H.M.C.) advising that bed-lifts were
necessary.
In May, 1965, the hospital medical staff committee (m.s.c..’ learned from a casual source that a decision had been reached to install stretcher-lifts during the current financial year. Immediate representations were made, urging that bed-lifts were necessary: early in July assurances were sought and obtained from the hospital secretary and from the house committee that any lifts installed would be capable of accommodating a bed. On July 30, 1965, however, at a meeting of the South Manchester H.M.c., on which no member of the medical stafl of this hospital sits, it was decided to accept the R.H.B.’S offer to install stretcher-lifts, since the board had made it clear that considerations of cost precluded the provision of bed-lifts. Minutes of H.M.C. meetings are sent to the secretaries of hospital M.s.c.s, but the minutes of this particular meeting were not sent until Oct. 8, 1965, and by the time their content was appreciated the contract for the lifts had already been given, and the contractors were ready to start. After representations by the M.s.c., the South Manchester H.M.C. agreed that stretcher-lifts would be unsatisfactory, and made representations to the regional board, requesting that plans for the lifts should be modified so that the lifts could accommodate a bed. The R.H.B. rejected these proposals, and indicated that the alternatives lay between having stretcherlifts and having no lifts at all. Faced with these alternatives the H.M.c., despite the appeals of the M.s.c., agreed to accept stretcher-lifts. The M.s.c., however, was unanimous in its opinion that the installation of stretcher-lifts or trolley-lifts would not increase materially the usage of the upstairs wards for medical and surgical emergencies, and for seriously ill patients. In its opinion the only way to obtain maximum bed-occupancy was to provide a lift or lifts capable of taking a bed and an attendant. It appreciated the help that it had received from the R.H.B. and the H.M.c., and was grateful that they should be willing to install lifts which were so badly needed in these wards. But the M.s.c. was unanimous that rather than have installed unsatisfactory lifts, which would preclude the future installation of bed-lifts, it would prefer to do without until such time as an adequate lift or lifts could be provided. Its reasons for this decision were as follows: reaching 1. The transfer of patients from stretchers or beds to trolleys in order to transport them upstairs, where they would again be transferred to a bed, would place a heavy burden on the nursing staff, and would cause discomfort and perhaps danger to patients. 2. Transfer of patients in this way between floors would greatly increase the amount of bed-making and use of bed-linen. 3. In an emergency it is vital to be able to move a patient rapidly between floors-e.g., in the event of sudden acute illness in a patient
upstairs.
4. Wards B4 and B5 each comprise a ward unit on two floors. In busy ward unit it is essential to maintain maximum flexibility of movement of patients. This could not be provided by trolley-lifts. 5. With the development of the cardiopulmonary unit in the new Wythenshawe Hospital, there will be a shortage of cardiothoracic beds, and since wards B4 and B5 are closest to the new unit they will be the most suitable to deal with acutely ill patients from that unit. a
deeply resentful of the fact that at no time hospital medical or nursing staffs consulted while these lifts were under consideration. They appealed against the decision to install stretcher-lifts to the H.M.C., to the R.H.B., and finally to the Minister of Health. The appeals failed. This was hardly surprising, but what rankles is that in rejecting the appeals each of the referees expressed satisfaction that the normal machinery for consultation had been available to all parties in the dispute, that the H.M.C. and R.H.B. had used this machinery, but that the M.s.c. had failed to avail itself of the proper consultative procedures. It is difficult to reconcile this opinion with the known facts of The
was
M.s.c. was
any member of the
the case, but there is no doubt that the records will show that consultation took place. Before this dispute is relegated to the dusty files of oblivion, one should perhaps ponder on the meaning of the word consultation ". To consult is to seek advice. In the present context consultation means discussion of a situation with interchange of ideas in order to resolve any difficulties on differences of opinion which may exist. It does not mean, as in this instance, that a decision is taken to provide an amenity without discussion with the users, whose opinions and advice are ignored. I believe that in the National Health Service, as in every walk of life, consultation is essential. But consultation must be made an active process and not remain just an empty word. "
Baguley Hospital, Wythenshawe, Manchester, 23.
T. M. WILSON.
CENTRAL STERILE SUPPLY SiR,ŅWhile any serious attempt to produce a paper specifically designed as an efficient bacterial barrier to meet the needs of both central sterile supply department (c.s.s.D.) and industry is to be applauded, too great stress on the inclusion of antibacterial agents as suggested by Mr. Fellows (Jan. 29) might well be misleading. The paper industry has for many years included antibacterial and antifungal agents during the actual manufacture of paper and board likely to be used or stored under conditions which would render them susceptible to spoilage. Substances such as o-phenylphenol (in glassine-type papers) and its water-soluble sodium salt, and particularly quaternary ammonium compounds, have been used. On the question of the maintenance of sterility, what good one wonders is a paper with an antifungal or antibacterial agent incorporated in it, if pinholes allow organisms to pass through unimpeded, and if organisms that come in contact with the paper are not moist ? On the latter point, we see no reason to doubt the validity of the work carried out at the Cross-Infection Reference Laboratory, Colindale,l on tests of self-disinfecting surfaces, which indicated that only surfaces which evolved formaldehyde showed any activity against dust-borne bacteria. The letter2 which prompted Mr. Fellows to write deserves some favourable comment, for it puts simply and concisely the various aspects of packaging for sterilised goods which are of prime importance to the hospital c.s.s.D. Particularly interesting were its comments on the use of paper. In practice pinhole-free paper, of even consistency, which does not allow the passage of bacteria in the dry or wet state, is ideal, and to this end a considerable amount of work has been carried out in this laboratory since the Nuffield report3 was published in 1958. In 1961 Hunter et al.4 demonstrated that papers of a certain 1. Kingston, D., Noble, W. C. J. Hyg., Camb. 1964, 62, 519. 2. Allen, S. M., et al. Lancet, 1965, ii, 1343. 3. Sterilisation Practice in Six Hospitals. Nuffield Provincial Hospitals Trust, London, 1958. 4. Hunter, C. L. F., Harbord, P. E., Riddett, D. J. in Symposium on Sterilisation of Surgical Materials. London, 1961.