BACTERIA IN THE AIR

457

CONVULSION THERAPY IN MENTAL DISORDER

figures given in the paper by Drs. STALKER,

MILLAR and JACOBS on another page, indicate that the benefits of shock treatment may consist rather in shortening the duration of the illness than in improving on the outcome attainable by less drastic LONDON: SATURDAY, FEBRUARY 25, 1939 methods. Various writers believe that in the reported results of cardiazol treatment in difCONVULSION THERAPY ferent centres are due in part to the differing degree THE Cardiazol treatment of schizophrenia has to which psychotherapy is utilised in the procedure. been following what seems the predestined course MEDUNA, who holds this view strongly, explains of any therapeutic method introduced into what lines his psychotherapy follows : it will many that the simple and kindly psychiatry. It has been extended to other forms appear to method he employs, mainly to lead of illness besides that for which it was proposed ; persuasive its theoretical basis has been questioned ; its the patient towards insight into the morbidity efficacy and mode of action are still in doubt after of his former delusions and hallucinations, is hardly four years of widespread trial ; and it has been likely to affect the course of the illness or the modified and combined with other methods to statistics materially, though it would of course the confusion of those who would like clear be a proper and helpful feature of the treatment. Among the risks of cardiazol treatment it is not proof of its usefulness. Many writers, such as VERSTRAETENand COOK,2 have reported success necessary to include death : 9 fatal cases among in the treatment of involutional melancholia, as well 2937 is not an alarming record on the whole ; though there have no doubt been other and unreported as isolated cases of benefit in mania, hysteria, obsessional states and other mental disorders ; indeed fatalities their number cannot be large, and so LEROY3 of Liege finds it still more widely applic- long as the selection and treatment of the patients able, since he would use it for eczema, urticaria, is carried out cautiously there is scarcely anything on this score. Dr. ATKIN communicates migraine and asthma. Although it was originally to fear another some observations on triazol, on page conceived because there seemed a " biological the related introduced by MAYER-GROSS analeptic antagonism " between epilepsy and schizophrenia, he has given a describes how and and WALK, the clinical observations from which this antagonism was inferred are now in dispute. Explanations supplementary dose when the first has not sufficed of what goes on in the cerebral tissues and the to cause a fit-a procedure that obviously calls great care if no undue risk is to be taken. He body fluids are numerous but there are still no for also mentions the possibility that pulmonary tuber-, satisfactory means of judging their correctness. culosis may be stirred up by the treatment. Of the Which type of schizophrenia does best with the treatment is also unsettled. Dr. IAN SKOTTOWE non-physical risks very little has been written. RilMEE 5 of Utrecht has seen patients whose conat last week’s meeting of the section of psychiatry of the Royal Society of Medicine suggested a dition was made worse by cardiazol, and others had had a similar untoward effect tripartite classification in which one of the groups, in whom insulin characterised by disorder of symbolic thinking and -namely, that they lost some of their schizoand without expression, included those who were unlikely to phrenic features but became apathetic and indifferent initiative, monotonous, vague, either cardiazol or insulin. do well with Dr. John to social has however, MEDUNA, requirements. BRANDER, speaking after him, questioned whether worked with not met Most of this. those who have either of these methods ever achieved results cardiazol will admire MEDUNA’S honesty and peculiar to them rather than to those who endorse his opinion when he writes: " As regards enthusiastically employed them : such scepticism enthusiasm, I must confess that I am not myself as this would generally, however, be thought excessive. It is commonly supposed that cardiazol enraptured with the cardiazol treatment, but benefits stuporose patients chiefly, but as MEDUNA for the present I do not know anything better I can recommend. In any case I regard it points out in his most recent paper4 different that observers have come to diametrically opposed as my duty to work as hard as I can at devising conclusions. MEDUNA himself does not think a procedure that obviates the apparently violent shock to the patient, while utilising only the biowe can yet iiay which groups of schizophrenics chemical processes to which the shock gives rise." will as in the statistics

THE LANCET

discrepancies

respond well ;

published

by Dr. REITMANN in our present issue, emphasis is rather put on the duration of the illness before cardiazol treatment is started. Comparison of the results with those obtained by other means is unsatisfactory, moreover, unless (among other things) the patient’s recovery or remission has always been assessed at approximately the same length of time after the conclusion of the course. Making due allowance for this, the interesting 1. Verstraeten, P., Ann. méd. psychol. 1937, 95, 654. 2. Cook, L. C., and Ogden, W., Lancet, 1938, 2, 885. 3. Leroy. A., J. belge Neurol. Psychiat. 1938, 38, 613. 4. Meduna, L. von, Psychiat. neurol. Bl., Amst. 1938, Nos. 5 and 6.

BACTERIA IN THE AIR WE have for many decades recognised that clean water and milk are essential if the spread of intestinal infection is to be limited. The importance of the air, as a vehicle for those pathogenic microorganisms that survive their immediate discharge from an infective source, has only recently received recognition. The state in which living bacteria are carried for long periods through the air is a matter for conjecture. There is both circumstantial 5.

Rümke, Ibid (discussion

on

Meduna’s

paper).

458

BACTERIA IN THE AIR

and

experimental evidence that most of the patho- lising power is, on the other hand, decreased by the genic bacteria in the air are spat, sneezed, talked presence on each droplet of a surface film of oil, and coughed into it from the respiratory tracts of which presents to the atmosphere a particularly men and animals. They may be as dry as dust, inert electrical field. Many antiseptics, highly but it is more likely that the natural affinity for lethal in bulk, are ineffective as aerosols ; and it is water possessed both by the bacteria and their possible that they are so because they induce in and the droplet a surface unsuitable for absorption of the mucus prevents complete drying, enveloping that the particles float about in a state of partial bacterial particle. Possibly too the greater resistance hydration. Air bacteria have been removed by to aerosol sterilisation that Dr. PULVERTAFT found filtration and killed by ultraviolet light, but such in the diphtheria bacillus is due not to any inherent methods involve the installation and maintenance resistance of its protoplasm to poison but to a of expensive plants. A room full of air may be surface inapt for absorption into a droplet. The mists are innocuous to man because, being cheaply and efficiently sterilised by some form of the but concentration of sparse, their average concentration in air is low; unfortunately antiseptic, that kills bacteria is they are effective presumably because of their an antiseptic gas or vapour equally poisonous for human protoplasm, and the power of absorbing bacteria. But the very air is not fit for use until the antiseptic has been properties which make them effective in air render removed. Sterility cannot be maintained while them inefficient for the sterilisation of solid human beings are in the room, for hitherto any surfaces. Dr. PULVERTAFT has shown that it is bearable concentration of antiseptic has been only on glass, rubber or metal that a test dose ineffective against the bacteria. It has now been of dried bacteria is killed. If the surface to be found, however, that by atomising a strong anti- sterilised is porous the mist is absorbed on to it ; septic solution the air can be filled with a mist so if the bacteria are wet-that is, relatively hydrated fine that the final concentration of antiseptic is -they will not absorb the mist, even on the most very small indeed, sometimes as low as one part favourable surfaces. For similar reasons it is in several millions. Dr. PULVERTAFT and his unlikely that aerosols penetrate far into cracks describe this issue experiments with and other narrow spaces. Not only are these in colleagues called Aerosols, that are capable bounded by absorbent surfaces but their narrowness antiseptic mists, of ridding the air of living bacteria. will prevent those mixing motions of the air that The aerosol consists of a suspension in air of ensure contact between bacterium and droplet. It liquid droplets about 1/200 of a millimetre in appears that the method may be applied with some diameter, which are small enough to remain in a certainty to large bodies of relatively still air. still atmosphere for many hours. They contain, The case for the sterilisation of continuously in addition to the antiseptic, substances with an replaced air is less well established ; it would at affinity for water, which prevent the rapid evapora- present be an expensive procedure to dose the airtion which would take place from the surface of a supply, for example, of a large ward with an pure-water droplet of the same size. The con- adequate concentration of antiseptic mist. centration of antiseptic in the droplets is thus There is need for more research into the nature about the same as that in the parent fluid. In the of the colloidal forces that obtain on the surface aerosol the distance between droplets is such that, of various air-borne particles. We know a good supposing them to be evenly distributed and deal about the way in which the behaviour of a immobilised in space, each droplet would have to bacterium in fluid suspension is determined by its

account for the death of all the bacteria round it, in an air space about 10,000 times its own volume. Since the antiseptic is not volatile the sterilisation of the air will obviously depend on the degree of mixing that takes place in the mist, and the

readiness with which the bacterial

surface but very little about the physicochemical state of bacteria or bacteria-containing particles in air. Further study of these floating particles will no doubt remove some of the limitations of sterilisation by aerosols. For the present, as Dr. PULVERTAFT points out, even partly effective methods are of value ; and we may be thankful for additional weapons against at least one kind of menace from the air.

particle absorbs antiseptic droplet, or the droplet the bacterial particle. Currents moving at a few millimetres per second can carry aerosol particles, and even in a quiet room bacteria and droplets will be continually approaching one another. Moreover, as the TONSILLECTOMY ON ITS DEFENCE mist slowly settles, the concentration of droplets, IN his report for 1923 as chief medical officer and therefore the frequency of approach, increases in the lower levels. Whether a bacterial particle of the Board of Education, Sir GEORGE NEWMAN coming into contact with a droplet will enter it, remarked that 47,000 operations for the removal depends on the nature of the two surfaces. Two of adenoids or enlarged tonsils had been performed particles of similar electrical charge, for example, during the year on children in schools maintained will repel one another. The readiness with which by local authorities. He adjured education mutual absorption of the two will take place is authorities and school medical officers to ensure determined by the physical and chemical differences that such operations were undertaken only when It was not sufficient, he between the bacterium and the antiseptic droplet. absolutely necessary. The electrical field on the surface of an aerosol said, for the school doctor merely to find local may be changed by the addition of surface-active inflammation or even hyperplasia; he should chemicals ; these increase sterilising power. Steri- satisfy himself in respect of each case that operative the