- Email: [email protected]
MEDICAL RESEARCH
242 Sterilisation of Instruments We might borrow from industry here, and pass the steel instruments-with the possible exception of knivesthrough an induction furnace. In two seconds the whole instrument-every molecule of the instrument-would simultaneously reach the required sterilisation temperature. The conveyor belt would then carry the instrument into a cooling fluid so that it would be completely sterile and cool within ten seconds. Such a steriliser could be in continuous use alongside the operating-table and yet not radiate any perceptible heat or steam. This would each advance the aseptic ideal-that instrument is used but once, then discarded. In a slightly pressurised theatre the basin steriliser could be heated to some degrees above 100°C without boiling, thus preventing excess water vapour being discharged into the theatre.
Asepsis
of
Antisepsis of Personnel personnel is impossible, but
should be made to keep the theatre atmosphere.
every effort
organisms from being shed
1. All theatre workers could have
a
into
spray in the airlock to
desquamated skin. 2. After drying, a complete rub over with a cloth damped with a mildly antiseptic oil-to prevent further shedding of epithelium and to cover the body with an antiseptic film. 3. It has been shown that carpenters working with hard wood
corporeal blood pumps and oxygenation, and it is more likely that blood substitutes will be used for oxygen carriage, in which case pressurised theatres will be a necessity (Boerema 1961, Boerema et al. 1960). Existing than
theatres cannot be modified for pressure, so that pres. surised theatres in future would have to be specially built.
With prefabrication and standard design, it is possible that a steel theatre would entail less capital expenditure. It would be more durable than stone or lime and plaster. If clean wound sepsis were reduced even by half, the shorter stay in hospital of patients would easily outweigh
capital expenditure. I am Western
grateful to Prof. J. W. Howie, Bacteriologist, Glasgow Infirmary, for advice and encouragement; and to William
Gallacher for his excellent
drawing. REFERENCES
Bert, P. (1878) C.R. Acad. Sci. 87, 782. Boerema, I. (1961) Surgery, 49, 291. Meyne, N. G., Brummelkamp, W. K., Bouma, S., Mensch, M. H., Kamermans, F., Stern Hanf, M., Aalderen, W. van (1960) J. Cardiov. Surg. 1, 133. Davey, O. G. (1959) Discovery, 216, 469. J. Inst. Hyg. Vent. Engrs (1959) 26, 257. Tindal, A. (1941) Surgo, 7, 33. —
remove
have sterile hands. Resins and oils in wood may account for this. If bare hands, well washed before an application of antiseptic resin or oil, were used at operation rather than rubber gloves (which tend to cause sweating and concentration of organisms) there would be less likelihood of tissues being inoculated with an infectious concentration of microorganisms. When a glove is punctured the resultant spillage is a highly concentrated bacterial emulsion, which the tissues are less likely to resist than the continual shedding of small numbers of microorganisms from the bare hand.
Theatre Garments Theatre fashions tend to protect the wearer rather than the patient. Long loose skirts blow the wearer’s desquamated epithelium about in clouds at every movement, while floppy, clumsy, rubber theatre-boots are hot to wear, cause sweating, and puff out foot dust at every step. To lessen the effect of flapping clothes, suitable theatre dress might be drainpipe slacks (fitting closely at the ankle), close-fitting singlet with short sleeves, socks and ballet shoes, or sandshoes. Sterile dress: short, closefitting, elastic jerkin with long sleeves tight at the wrist, tying at the back, with elastic round the trochanters. At present, because of voluminous garments, surgeons and nurses often touch non-sterile objects without being aware
of
doing
so.
All the above may seem too fantastic and unrealistic, but researchers went to far greater lengths to produce sterile rats (Davey 1959), and in I.C.I. laboratories a more exacting. aseptic ceremonial is enforced even to see these
disease-free
rats.
Conclusions To be successful the technique of
asepsis
must
be
approach perfection. more
and
more
THE Medical Research Council had its beginnings in the world of fifty years ago in which the value of scientific research was suspect. Now that the need for such research is taken for granted, the Council’s role has changed. Its latest annual report1 discusses the present functions of a central research organisation. The Council sees itself as the coordinator of resources on a national scale. Working in partnership with other establishments, it supports judiciously selected research projects. In making this selection, it must bear in mind the country’s probable future needs; but it must never allow this direction of aim to become so rigid that individual workers are unable to act on their own initiative. The Council’s status as an independent body, advised by a widely experienced board, fits it to provide opinions which can be trusted by Government and public alike. Some of the work in the report.
supported by the Council is reviewed
Brain Mechanisms A technique for injecting drugs painlessly into the cerebral ventricles of unanxsthetised animals is being used to explore the physiological basis of some of the physical symptoms of mental disorder. Some drugs-e.g., adrenaline, noradrenaline, and calcium chloride-which have an excitatory effect when given systemically are depressants when introduced directly into the cerebrospinal fluid: the animal shows a disturbance of consciousness similar to sleep or anaesthesia. Some established narcotics (chloral, chloralose, and magnesium chloride) have the same effect when given intraventricularly in very small doses. Sleep is sometimes preceded by compulsive eating, the animal often falling asleep at the dish of food. This is believed to be due to the drugs’ effect on the hypothalamic centres
controlling appetite.
highly efficient. This is impossible with modern operating-theatre design, ventilation, and discipline; and, unless the technique is beyond criticism, it might be safer to In a theatre suite as outlined, an revert to antisepsis. aseptic technique could be practised that would at least Further advances will
MEDICAL RESEARCH
depend
on extra-
Catatonia or hallucinations reminiscent of schizophrenia follow the introduction of acetylcholine or diisopropylfluorophosphonate (D.F.P.) into the ventricles: the animal maintains unnatural postures, although it is not paralysed, for, when
disturbed, attacks of
it
can
move
normally.
D.F.P.
produces
acute
in schizophrenics; but the disease is not due to the necessarily persistence of acetylcholine at some brain locus. All that can be concluded is that such persistence, 1.
psychosis
Report of the Medical Research Council for the H.M. Stationery Office.
year
1960-1961.
243
by prolonging depolarisation, reproduces the neuronal damage and dysfunction of schizophrenia. In the cat, the introduction of D.F.P. into the ventricles may be followed by the complicated coordinated movements of washing, licking, and scratching.
Mental Disorder in Old Age
high incidence of mental disorder among people over prompted the Council to inquire into the contributing aetiological factors. The importance of the problem was emphasised by a report from Durham. Of three hundred and six people over 65, randomly selected, 10% had definable The 65 has
psychiatric illness.
Affective disorders in old age
are
often attributed to arterio-
sclerotic senile dementia. The underlying neuropathology has been clarified to some extent by a survey of three hundred consecutive cases, in which the clinical diagnosis was compared with the postmortem findings. In about 75 % of those diagnosed as affective or paranoid, cerebral changes-senile plaques, neurofibrillary changes, or evidence of vascular diseaseIn a similar percentage of those diagnosed as were slight. arteriosclerotic, the pathological changes were moderate or severe. But in the remaining 25%, clinical and postmortem findings could not be reconciled, and the degree of this " overlap " increased in the older age-groups. An investigation of schizophrenia of late onset showed that, although the risk of the disease developing in collaterals was higher than among the general population, it was not as great as that found for the first-degree relatives of patients who develop the disease before 60. Thus, environmental, rather than genetic,
Medicine and the Law Psychotic Delusions in
Matrimonial Suits A HUSBAND and wife were married in 1956, when the husband was 41 and the wife 34. The marriage was never happy, but they continued to live together until January, 1960, when the wife, after an attempt at suicide, was taken
nursing-home. Subsequently the husband petitioned for divorce on the ground of cruelty. The wife denied cruelty and pleaded that if she had ill-treated the husband, she was not responsible in law in that she had a defect of reason due to disease of the mind, and did not know the nature or quality of her acts or that what she did was to a
wrong. The wife had accused the husband of being more interested than he should have been in other women. He told her that her accusations were unjustified, as was the case, but she persisted and in the autumn of 1959 accused him of a wrong relationship with another woman and of homosexual relations with three tenants of part of the matrimonial home. She also taunted him with having married her for her money. At the end of November, 1959, without any provocation, she kicked him sharply while in bed. By that time she was accusing him, their tenants, and the cleaner of being in league against her. During December, 1959, she assaulted her husband twice. On Jan. 2, 1960, she attempted suicide, being saved from death only by the arrival home of the husband. Thereafter, she was treated in a nursing-home for some weeks.
Justice ScARMAN said that, on the medical evidence, satisfied that from September, 1959, until Jan. 2, the wife had a paranoid psychosis, the effect of 1960, which was that she had delusions centring on her husband, whom she saw as a hostile figure conspiring with others against her. But save for her delusions she was a rational being, able to distinguish between right and wrong. It followed that her responsibility at lawassuming, as the Court must, that the McNaughten rules applied-was to be determined as though her delusions were true. As she did not know; when she made the Mr.
he
was
factors seem to be important; physical illness, incapacity, and poverty were common among these patients. Dental Caries Dental caries has also been studied in detail. The precise aetiology of the lesions has still not been clarified, but the essential role of purified fermentable carbohydrate in combination with bacteria has been confirmed. The carious agent first penetrates the enamel along the " incremental strix " formed during growth of the tooth. A soluble fraction of the organic matrix is then destroyed and decalcification follows; finally, bacteria invade the spaces so formed. Now that this sequence has been established, it may be possible to attack caries by somehow rendering the soluble organic matrix insoluble, or by preventing the developmental faults along which the carious agent first penetrates. Air Pollution Since the dramatic fog of 1952, the Council has studied air pollution, with especial reference to chronic bronchitis and lung cancer. In a busy street in calm weather, the concentration of carbon monoxide in the air may exceed that regarded as safe for 8 hours’ industrial exposure. Moreover, urban air contains appreciable amounts of nitrous oxide, whose affinity for hxmoglobin exceeds that of carbon monoxide. The concentration of the carcinogen, 3:4 benzpyrene, in the air of the Blackwall Tunnel has been found to be no higher than that in London streets on a foggy day. The operation of the Clean Air Act should provide an interesting epidemiological situation which the Medical Research Council is prepared to exploit.
accusations, that she was doing wrong she was not responsible in law for them. When, however, she used physical violence towards the husband, she knew that what she was doing was wrong. Certainly the converse, that she did not know, had not been established. The assaults were intended to hurt the husband and did so; they could properly found an apprehension of future injury. They therefore constituted legal cruelty and the husband was entitled
to a
decree nisi of divorce.
Elphinstone Elphinstone—Probate, Divorce and Admiralty Division: Scarman, J., May 3, 1962. Counsel and solicitors: David Karmel, Q.C., and H. S. Law (Braby & Waller); G. H. Crispin, Q.C., and D. R. Stuckey (Culross & Co.). DONALD ELLISON v.
Barrister-at-Law.
The
Unregistered Dentist AN unregistered dentist was acquitted at West Ham Quarter Sessions on each of nine charges of unlawful practice.1 These alleged that he had three times taken impressions of the mouth and jaw, four times inserted and fitted dental fixtures, once assisted with a filling, and once examined a patient’s mouth. Four patients testified to these charges, but agreed that a registered dentist was working with the accused and that the standard of dentistry had always been satisfactory. The accused dentist said that for eight years he had worked on a percentage basis with a registered dentist. He acted as chair-side assistant, doing the technical and clerical work. The Recorder, Mr. Walter Raeburn, Q.c., said that the Dentists’ Act was ambiguous; it required dental surgery to be done under the supervision of a registered dentist and in accordance with conditions approved by the Minister of Health and the General Dental Council, but these conditions had never been defined. The difficulty lay in drawing a distinction between major and minor dental work. Mr. Raeburn held that surgery was the essence of dentistry and that the rest was minor. All the procedures mentioned in the charges were in this minor category and therefore permissible under the Act. Prosecuting Counsel asked that the Recorder’s decision be submitted to the High Court for an opinion. 1.
Guardian, July 26,
1962.
Asepsis
of
Antisepsis of Personnel personnel is impossible, but
should be made to keep the theatre atmosphere.
every effort
organisms from being shed
1. All theatre workers could have
a
into
spray in the airlock to
desquamated skin. 2. After drying, a complete rub over with a cloth damped with a mildly antiseptic oil-to prevent further shedding of epithelium and to cover the body with an antiseptic film. 3. It has been shown that carpenters working with hard wood
corporeal blood pumps and oxygenation, and it is more likely that blood substitutes will be used for oxygen carriage, in which case pressurised theatres will be a necessity (Boerema 1961, Boerema et al. 1960). Existing than
theatres cannot be modified for pressure, so that pres. surised theatres in future would have to be specially built.
With prefabrication and standard design, it is possible that a steel theatre would entail less capital expenditure. It would be more durable than stone or lime and plaster. If clean wound sepsis were reduced even by half, the shorter stay in hospital of patients would easily outweigh
capital expenditure. I am Western
grateful to Prof. J. W. Howie, Bacteriologist, Glasgow Infirmary, for advice and encouragement; and to William
Gallacher for his excellent
drawing. REFERENCES
Bert, P. (1878) C.R. Acad. Sci. 87, 782. Boerema, I. (1961) Surgery, 49, 291. Meyne, N. G., Brummelkamp, W. K., Bouma, S., Mensch, M. H., Kamermans, F., Stern Hanf, M., Aalderen, W. van (1960) J. Cardiov. Surg. 1, 133. Davey, O. G. (1959) Discovery, 216, 469. J. Inst. Hyg. Vent. Engrs (1959) 26, 257. Tindal, A. (1941) Surgo, 7, 33. —
remove
have sterile hands. Resins and oils in wood may account for this. If bare hands, well washed before an application of antiseptic resin or oil, were used at operation rather than rubber gloves (which tend to cause sweating and concentration of organisms) there would be less likelihood of tissues being inoculated with an infectious concentration of microorganisms. When a glove is punctured the resultant spillage is a highly concentrated bacterial emulsion, which the tissues are less likely to resist than the continual shedding of small numbers of microorganisms from the bare hand.
Theatre Garments Theatre fashions tend to protect the wearer rather than the patient. Long loose skirts blow the wearer’s desquamated epithelium about in clouds at every movement, while floppy, clumsy, rubber theatre-boots are hot to wear, cause sweating, and puff out foot dust at every step. To lessen the effect of flapping clothes, suitable theatre dress might be drainpipe slacks (fitting closely at the ankle), close-fitting singlet with short sleeves, socks and ballet shoes, or sandshoes. Sterile dress: short, closefitting, elastic jerkin with long sleeves tight at the wrist, tying at the back, with elastic round the trochanters. At present, because of voluminous garments, surgeons and nurses often touch non-sterile objects without being aware
of
doing
so.
All the above may seem too fantastic and unrealistic, but researchers went to far greater lengths to produce sterile rats (Davey 1959), and in I.C.I. laboratories a more exacting. aseptic ceremonial is enforced even to see these
disease-free
rats.
Conclusions To be successful the technique of
asepsis
must
be
approach perfection. more
and
more
THE Medical Research Council had its beginnings in the world of fifty years ago in which the value of scientific research was suspect. Now that the need for such research is taken for granted, the Council’s role has changed. Its latest annual report1 discusses the present functions of a central research organisation. The Council sees itself as the coordinator of resources on a national scale. Working in partnership with other establishments, it supports judiciously selected research projects. In making this selection, it must bear in mind the country’s probable future needs; but it must never allow this direction of aim to become so rigid that individual workers are unable to act on their own initiative. The Council’s status as an independent body, advised by a widely experienced board, fits it to provide opinions which can be trusted by Government and public alike. Some of the work in the report.
supported by the Council is reviewed
Brain Mechanisms A technique for injecting drugs painlessly into the cerebral ventricles of unanxsthetised animals is being used to explore the physiological basis of some of the physical symptoms of mental disorder. Some drugs-e.g., adrenaline, noradrenaline, and calcium chloride-which have an excitatory effect when given systemically are depressants when introduced directly into the cerebrospinal fluid: the animal shows a disturbance of consciousness similar to sleep or anaesthesia. Some established narcotics (chloral, chloralose, and magnesium chloride) have the same effect when given intraventricularly in very small doses. Sleep is sometimes preceded by compulsive eating, the animal often falling asleep at the dish of food. This is believed to be due to the drugs’ effect on the hypothalamic centres
controlling appetite.
highly efficient. This is impossible with modern operating-theatre design, ventilation, and discipline; and, unless the technique is beyond criticism, it might be safer to In a theatre suite as outlined, an revert to antisepsis. aseptic technique could be practised that would at least Further advances will
MEDICAL RESEARCH
depend
on extra-
Catatonia or hallucinations reminiscent of schizophrenia follow the introduction of acetylcholine or diisopropylfluorophosphonate (D.F.P.) into the ventricles: the animal maintains unnatural postures, although it is not paralysed, for, when
disturbed, attacks of
it
can
move
normally.
D.F.P.
produces
acute
in schizophrenics; but the disease is not due to the necessarily persistence of acetylcholine at some brain locus. All that can be concluded is that such persistence, 1.
psychosis
Report of the Medical Research Council for the H.M. Stationery Office.
year
1960-1961.
243
by prolonging depolarisation, reproduces the neuronal damage and dysfunction of schizophrenia. In the cat, the introduction of D.F.P. into the ventricles may be followed by the complicated coordinated movements of washing, licking, and scratching.
Mental Disorder in Old Age
high incidence of mental disorder among people over prompted the Council to inquire into the contributing aetiological factors. The importance of the problem was emphasised by a report from Durham. Of three hundred and six people over 65, randomly selected, 10% had definable The 65 has
psychiatric illness.
Affective disorders in old age
are
often attributed to arterio-
sclerotic senile dementia. The underlying neuropathology has been clarified to some extent by a survey of three hundred consecutive cases, in which the clinical diagnosis was compared with the postmortem findings. In about 75 % of those diagnosed as affective or paranoid, cerebral changes-senile plaques, neurofibrillary changes, or evidence of vascular diseaseIn a similar percentage of those diagnosed as were slight. arteriosclerotic, the pathological changes were moderate or severe. But in the remaining 25%, clinical and postmortem findings could not be reconciled, and the degree of this " overlap " increased in the older age-groups. An investigation of schizophrenia of late onset showed that, although the risk of the disease developing in collaterals was higher than among the general population, it was not as great as that found for the first-degree relatives of patients who develop the disease before 60. Thus, environmental, rather than genetic,
Medicine and the Law Psychotic Delusions in
Matrimonial Suits A HUSBAND and wife were married in 1956, when the husband was 41 and the wife 34. The marriage was never happy, but they continued to live together until January, 1960, when the wife, after an attempt at suicide, was taken
nursing-home. Subsequently the husband petitioned for divorce on the ground of cruelty. The wife denied cruelty and pleaded that if she had ill-treated the husband, she was not responsible in law in that she had a defect of reason due to disease of the mind, and did not know the nature or quality of her acts or that what she did was to a
wrong. The wife had accused the husband of being more interested than he should have been in other women. He told her that her accusations were unjustified, as was the case, but she persisted and in the autumn of 1959 accused him of a wrong relationship with another woman and of homosexual relations with three tenants of part of the matrimonial home. She also taunted him with having married her for her money. At the end of November, 1959, without any provocation, she kicked him sharply while in bed. By that time she was accusing him, their tenants, and the cleaner of being in league against her. During December, 1959, she assaulted her husband twice. On Jan. 2, 1960, she attempted suicide, being saved from death only by the arrival home of the husband. Thereafter, she was treated in a nursing-home for some weeks.
Justice ScARMAN said that, on the medical evidence, satisfied that from September, 1959, until Jan. 2, the wife had a paranoid psychosis, the effect of 1960, which was that she had delusions centring on her husband, whom she saw as a hostile figure conspiring with others against her. But save for her delusions she was a rational being, able to distinguish between right and wrong. It followed that her responsibility at lawassuming, as the Court must, that the McNaughten rules applied-was to be determined as though her delusions were true. As she did not know; when she made the Mr.
he
was
factors seem to be important; physical illness, incapacity, and poverty were common among these patients. Dental Caries Dental caries has also been studied in detail. The precise aetiology of the lesions has still not been clarified, but the essential role of purified fermentable carbohydrate in combination with bacteria has been confirmed. The carious agent first penetrates the enamel along the " incremental strix " formed during growth of the tooth. A soluble fraction of the organic matrix is then destroyed and decalcification follows; finally, bacteria invade the spaces so formed. Now that this sequence has been established, it may be possible to attack caries by somehow rendering the soluble organic matrix insoluble, or by preventing the developmental faults along which the carious agent first penetrates. Air Pollution Since the dramatic fog of 1952, the Council has studied air pollution, with especial reference to chronic bronchitis and lung cancer. In a busy street in calm weather, the concentration of carbon monoxide in the air may exceed that regarded as safe for 8 hours’ industrial exposure. Moreover, urban air contains appreciable amounts of nitrous oxide, whose affinity for hxmoglobin exceeds that of carbon monoxide. The concentration of the carcinogen, 3:4 benzpyrene, in the air of the Blackwall Tunnel has been found to be no higher than that in London streets on a foggy day. The operation of the Clean Air Act should provide an interesting epidemiological situation which the Medical Research Council is prepared to exploit.
accusations, that she was doing wrong she was not responsible in law for them. When, however, she used physical violence towards the husband, she knew that what she was doing was wrong. Certainly the converse, that she did not know, had not been established. The assaults were intended to hurt the husband and did so; they could properly found an apprehension of future injury. They therefore constituted legal cruelty and the husband was entitled
to a
decree nisi of divorce.
Elphinstone Elphinstone—Probate, Divorce and Admiralty Division: Scarman, J., May 3, 1962. Counsel and solicitors: David Karmel, Q.C., and H. S. Law (Braby & Waller); G. H. Crispin, Q.C., and D. R. Stuckey (Culross & Co.). DONALD ELLISON v.
Barrister-at-Law.
The
Unregistered Dentist AN unregistered dentist was acquitted at West Ham Quarter Sessions on each of nine charges of unlawful practice.1 These alleged that he had three times taken impressions of the mouth and jaw, four times inserted and fitted dental fixtures, once assisted with a filling, and once examined a patient’s mouth. Four patients testified to these charges, but agreed that a registered dentist was working with the accused and that the standard of dentistry had always been satisfactory. The accused dentist said that for eight years he had worked on a percentage basis with a registered dentist. He acted as chair-side assistant, doing the technical and clerical work. The Recorder, Mr. Walter Raeburn, Q.c., said that the Dentists’ Act was ambiguous; it required dental surgery to be done under the supervision of a registered dentist and in accordance with conditions approved by the Minister of Health and the General Dental Council, but these conditions had never been defined. The difficulty lay in drawing a distinction between major and minor dental work. Mr. Raeburn held that surgery was the essence of dentistry and that the rest was minor. All the procedures mentioned in the charges were in this minor category and therefore permissible under the Act. Prosecuting Counsel asked that the Recorder’s decision be submitted to the High Court for an opinion. 1.
Guardian, July 26,
1962.