- Email: [email protected]
PROTECTING CHRYSANTHEMUMS FROM HOSPITAL INFECTION
267 carcinoma behaves in a most sinister fashion and where radical surgical excision is mandatory. Welsh Regional Plastic Surgery
Centre, St. Lawrence Hospital, Chepstow, Monmouthshire.
MICHAEL N. TEMPEST.
STEREOTAXY FOR OBESITY
SIR,-In your editorial, Infant and Adult Obesity (Jan. 5, p. 17), our therapeutic experiment with hypothalamic stereotaxy, the first of its
kind, is commented on as
follows:
"
It shows how ineffective the simpler forms of treatment are that anyone should think it reasonable to produce irreversible intracranial lesions in very obese patients."
Since December, 1971, we have subjected five patients with gross obesity (118-180 kg.) to an electrostimulatory exploration of the lateral hypothalamic area. In three cases a convincing hunger response was elicited. Two of these patients received unilateral electrocoagulatory lesions, and in the third a contralateral (left-sided) coagulation was performed three months later. In contrast to the two patients who had only been explored, the patients with lesions showed a statistically significant, but transient, decrease from preoperative to postoperative spontaneous calorie intake (see accompanying figure). Body-weights
PROTECTING CHRYSANTHEMUMS FROM HOSPITAL INFECTION
SIR,-Observations on the part possibly played by flowers, particularly chrysanthemums, and by the water in the vases, in the spread of infection 1-4 have caused anxiety. Whether chrysanthemums are the victims or the source of bacterial infection can only be settled by starting literally in the field and examining the stages in handling (see table i). If bunched flowers or pot plants are swabbed on admission very few organisms indeed will be found-e.g., 3 staphylococci for a pot of African violets. The situation once the flowers are in the ward is different. From both a dry cracked vase and a dry intact vase 1010 TABLE I-BACTERIAL FLORA ON CHRYSANTHEMUM LEAVES
For tap-water kept at room were isolated. temperature for 3 days the numbers of organisms isolated in unwashed vase containing standard were as follows: flowers 1010 per ml.; in presterilised vase containing standard flowers 1010 per ml.; in unwashed vase with no flowers 109 per ml.; in presterilised vase with no flowers 10 per ml.
organisms
The " standard flowers " were a mixture of tulips, anemones, and chrysanthemums distributed so that each test had equal numbers from each bunch; none had been in the wards. Incubation before sampling was by leaving in a small room with still air.
does not suggest that hospital infection in the wards where there are most flowers. On the contrary, the women’s wards and private wards have more flowers and less infections than the men’s wards. The entire floral display of one women’s surgical ward was sampled and a total population of 2 x 1014 was estimated for the open containers; no pseudomonas were isolated on selective medium. The rarity of wound or any other infection in that ward suggests that the organisms do not normally take off from the vase. To confirm this, the air in a cubicle was sampled as a control, then the dying flowers in two vases were placed 15 cm. from a slit sampler. The number of organisms isolated were as follows:
Experience
occurs
and spontaneous calorie intake in an obese patient before and after bilateral electrocoagulation of the lateral
Body-weight
hypothalamus.
DXT.=right; SIN. = left.
and temporarily, but were not signiWe conclude that in man, as in laboratory ficantly affected. animals, the lateral hypothalamus is the site of nuclei or tracts that are related to hunger. Our justification in attempting the operation is, of course, the very poor results of conventional therapy in gross obesity, and the dark prognosis, mental and physical, of the uncorrected condition. We have also taken into account the high technical development in recent years of stereotaxic brain surgery and the absence of complications after electrocoagulatory lesions of other areas of the hypothalamus. In our view hypothalamic stereotaxy is a logical and causal approach and a more limited intervention than, e.g., jejuno-ileal anastomosis.
decreased
slightly
Medical Department B,
Bispebjerg Hospital, University of Copenhagen, Denmark.
FLEMMING
QUAADE.
Quaade, F. Proceedings of Obesity Symposium, London, Dec. 4-5, 1973. Edinburgh (in the press). 2. Quaade, F., Værnet, K., Larsson, S. Acta neurochir. (in the press). 1.
min. (350 c.ft.) Control With two
vases
of flowers
6 3
2 min.
(1400 c./r.) 9 10
Whatever the rules about ward flowers, they are, in fact, put into water and changed at the sink in the ward by the patients and their visitors; the staff have not the time to do this. If scrubbing up is done later in the same sink an aerosol of any specific organism there can be detected by settle plates for a distance of at least 4 ft., although the hands themselves are not contaminated. The value of antiseptics in dealing with spillage of infected flower water was estimated by titration (table 11). The marked inhibition by the plant sap is unlikely to be due to protein binding, since the highest value found was only 6 mg. per 100 ml. in very thick and foul water.
268 TABLE II-MINIMUM DILUTION OF ANTISEPTICS TO SECURE STERILITY
.
We have found that the effect of hypochlorite in the Survival of the presence of the flowers is satisfactory. flowers-chrysanthemums, daffodils, anemones, and tulips -appeared to be unaffected by the hypochlorite. Apparently the flowers themselves are innocent victims of the ward environment. The following procedure seems reasonable. All flower water should be treated with 10 ml. of 1 % hypochlorite, or an equivalent 40 ml. ofEusol’, each time it is changed. Flower water should be disposed of whenever possible down a sluice or water closet and not in a hand-basin or sink used for scrubbing up. Spills of flower water should be mopped up as carefully as blood or excreta.
Department of Bacteriology, St. Mary’s Hospital Medical School, London W2 1PG.
W. HOWARD HUGHES.
Teres, D., Scheers, P., Bushnell, L. S., Hedley-Wright, J., Feingold, D. S. Lancet, 1973, i, 415. 2. Watson, A. G., Koons, C. E. ibid. 1973, ii, 91. 3. Rosenzweig, A. L. ibid. p. 598. 4. Taplin, D., Mertz, P. M. ibid. p. 1279. 1.
OPEN UNIVERSITY MEDICAL SCHOOL ? SiR,—We have no doubt that there are many adults in this country, with or without the relevant A-level qualifications, who would make excellent doctors but who, at present, have no possibility of studying medicine. For this reason the proposals for a degree course in medicine at the Open University, described in your editorial (Jan. 12, p. 54) and in the Guardian of Dec. 31, should be seriously debated. Furthermore, given a need for more medical students, the Open University could ease the cost of expanding preclinical teaching, and from a national point of view the balance of the economic arguments seems to favour the proponents of such a course. We believe that a considerable problem has to be faced in teaching the preclinical subjects by Open University methods. Practical work in anatomy and physiology, which is essential to a proper grasp of the subject, cannot be done in the student’s home, because of the need to use living or dead human material, animals, or expensive equipment. This could perhaps be met by residential courses, either in existing medical schools during vacations or eventually in a new school of the Open University, which would be appreciably longer than the customary Open University summer residential courses but would still represent a great economy. Dr Walter
Perry’s objections regarding the problems of clinical teaching are less easily dismissed. We do not think that the scheme of the Open University Society for Medical Science of using district general hospitals and postgraduate medical training centres is practicable, or would allow the University to exercise adequate control over clinical teaching. The Society exaggerates the amount of " dead " time in present full-time medical courses; if the clinical period was also part-time it is very doubtful if the whole course could be covered in 6 years. Professor Acheson (Jan. 5, p. 26) has suggested that some of the established medical schools should be asked to each take a small number of clinical students from the
Open University. This seems a much better proposition, and indeed there is an excellent precedent in the traditional practice of the London medical schools in taking students from Oxford and Cambridge. A corollary of this solution would be the need for financial support to Open University students during their period of clinical training. Since some of them will be previously earning normal adult incomes, this support would have to be generous and flexible. Perhaps the Department of Education and Science could be persuaded to provide State grants. If the Open University does consider instituting a course of this sort we suggest that it should take the opportunity to establish a degree course in human biology or human sciences, rather than’just a preclinical course. Several universities have established such courses and others are considering doing so. Of the existing courses of this type, those at Cambridge, Nottingham, and, from next October, St. Andrews, serve as preclinical courses. The latter is relevant to the Open University proposal in that their students will do their clinical studies at Manchester. Such a course would enable students wishing to take the broader type of degree, favoured by the University Grants Committee and other bodies, to do so. Those wishing to consider studying medicine would have to register as such initially and take the required options, but would not need to be finally committed before obtaining their degree in human biology. It would provide the opportunity for those aiming at medicine to meet students with a different approach during tutorial sessions, and from the Open University’s point of view would make the whole exercise more worth while.
School of Biological Sciences and School of Medicine, University of Leeds.
R. A. BAKER S. BAUMBERG M. D’A. CRAWFURD G. R. HERVEY B. E. C. NORDIN.
SIR,-Having for half a lifetime been an alert observer of the social structure from the viewpoint of a university administrator with special concern for admissions and counselling in schools, my heart was warmed by Professor Acheson’s letter (Jan. 5, p. 26) accepting with enthusiasm the idea of a medical school attached to the Open University. In the United Kingdom we have not gone in for much social planning in the past, but when it is observed that we are not able or willing, for reasons of financial or other deficiencies, to make medical training available to those who would wish to become doctors, and who would be capable of fulfilling the requirements of the course, then it would be reasonable to ask ourselves if this is the best we can do. Very large investments have been made in medical schools by the public exchequer since the 1939-45 war, and while these investments have drastically changed every aspect of the professional scene within the schools and universities, including teaching, research, and administration, there has not been a commensurate development in the size of the schools measured by the number of students-the productivity increase resulting from the expanded investment has been proportioned to increase the establishment more than the output of doctors. In these circumstances it would be realistic for society to look at the matter again in the context not only of the profession itself and its authoritative bodies, but in that of society as a whole. The Open University is supplying a social need which the existing universities declined to do, or found themselves unable to do, but it would really be a better solution to the problem if the existing medical schools would produce the revolutionary idea. 14 Osborne Gardens, Belfast BT9 6LE.
J. M. FREELAND.
Centre, St. Lawrence Hospital, Chepstow, Monmouthshire.
MICHAEL N. TEMPEST.
STEREOTAXY FOR OBESITY
SIR,-In your editorial, Infant and Adult Obesity (Jan. 5, p. 17), our therapeutic experiment with hypothalamic stereotaxy, the first of its
kind, is commented on as
follows:
"
It shows how ineffective the simpler forms of treatment are that anyone should think it reasonable to produce irreversible intracranial lesions in very obese patients."
Since December, 1971, we have subjected five patients with gross obesity (118-180 kg.) to an electrostimulatory exploration of the lateral hypothalamic area. In three cases a convincing hunger response was elicited. Two of these patients received unilateral electrocoagulatory lesions, and in the third a contralateral (left-sided) coagulation was performed three months later. In contrast to the two patients who had only been explored, the patients with lesions showed a statistically significant, but transient, decrease from preoperative to postoperative spontaneous calorie intake (see accompanying figure). Body-weights
PROTECTING CHRYSANTHEMUMS FROM HOSPITAL INFECTION
SIR,-Observations on the part possibly played by flowers, particularly chrysanthemums, and by the water in the vases, in the spread of infection 1-4 have caused anxiety. Whether chrysanthemums are the victims or the source of bacterial infection can only be settled by starting literally in the field and examining the stages in handling (see table i). If bunched flowers or pot plants are swabbed on admission very few organisms indeed will be found-e.g., 3 staphylococci for a pot of African violets. The situation once the flowers are in the ward is different. From both a dry cracked vase and a dry intact vase 1010 TABLE I-BACTERIAL FLORA ON CHRYSANTHEMUM LEAVES
For tap-water kept at room were isolated. temperature for 3 days the numbers of organisms isolated in unwashed vase containing standard were as follows: flowers 1010 per ml.; in presterilised vase containing standard flowers 1010 per ml.; in unwashed vase with no flowers 109 per ml.; in presterilised vase with no flowers 10 per ml.
organisms
The " standard flowers " were a mixture of tulips, anemones, and chrysanthemums distributed so that each test had equal numbers from each bunch; none had been in the wards. Incubation before sampling was by leaving in a small room with still air.
does not suggest that hospital infection in the wards where there are most flowers. On the contrary, the women’s wards and private wards have more flowers and less infections than the men’s wards. The entire floral display of one women’s surgical ward was sampled and a total population of 2 x 1014 was estimated for the open containers; no pseudomonas were isolated on selective medium. The rarity of wound or any other infection in that ward suggests that the organisms do not normally take off from the vase. To confirm this, the air in a cubicle was sampled as a control, then the dying flowers in two vases were placed 15 cm. from a slit sampler. The number of organisms isolated were as follows:
Experience
occurs
and spontaneous calorie intake in an obese patient before and after bilateral electrocoagulation of the lateral
Body-weight
hypothalamus.
DXT.=right; SIN. = left.
and temporarily, but were not signiWe conclude that in man, as in laboratory ficantly affected. animals, the lateral hypothalamus is the site of nuclei or tracts that are related to hunger. Our justification in attempting the operation is, of course, the very poor results of conventional therapy in gross obesity, and the dark prognosis, mental and physical, of the uncorrected condition. We have also taken into account the high technical development in recent years of stereotaxic brain surgery and the absence of complications after electrocoagulatory lesions of other areas of the hypothalamus. In our view hypothalamic stereotaxy is a logical and causal approach and a more limited intervention than, e.g., jejuno-ileal anastomosis.
decreased
slightly
Medical Department B,
Bispebjerg Hospital, University of Copenhagen, Denmark.
FLEMMING
QUAADE.
Quaade, F. Proceedings of Obesity Symposium, London, Dec. 4-5, 1973. Edinburgh (in the press). 2. Quaade, F., Værnet, K., Larsson, S. Acta neurochir. (in the press). 1.
min. (350 c.ft.) Control With two
vases
of flowers
6 3
2 min.
(1400 c./r.) 9 10
Whatever the rules about ward flowers, they are, in fact, put into water and changed at the sink in the ward by the patients and their visitors; the staff have not the time to do this. If scrubbing up is done later in the same sink an aerosol of any specific organism there can be detected by settle plates for a distance of at least 4 ft., although the hands themselves are not contaminated. The value of antiseptics in dealing with spillage of infected flower water was estimated by titration (table 11). The marked inhibition by the plant sap is unlikely to be due to protein binding, since the highest value found was only 6 mg. per 100 ml. in very thick and foul water.
268 TABLE II-MINIMUM DILUTION OF ANTISEPTICS TO SECURE STERILITY
.
We have found that the effect of hypochlorite in the Survival of the presence of the flowers is satisfactory. flowers-chrysanthemums, daffodils, anemones, and tulips -appeared to be unaffected by the hypochlorite. Apparently the flowers themselves are innocent victims of the ward environment. The following procedure seems reasonable. All flower water should be treated with 10 ml. of 1 % hypochlorite, or an equivalent 40 ml. ofEusol’, each time it is changed. Flower water should be disposed of whenever possible down a sluice or water closet and not in a hand-basin or sink used for scrubbing up. Spills of flower water should be mopped up as carefully as blood or excreta.
Department of Bacteriology, St. Mary’s Hospital Medical School, London W2 1PG.
W. HOWARD HUGHES.
Teres, D., Scheers, P., Bushnell, L. S., Hedley-Wright, J., Feingold, D. S. Lancet, 1973, i, 415. 2. Watson, A. G., Koons, C. E. ibid. 1973, ii, 91. 3. Rosenzweig, A. L. ibid. p. 598. 4. Taplin, D., Mertz, P. M. ibid. p. 1279. 1.
OPEN UNIVERSITY MEDICAL SCHOOL ? SiR,—We have no doubt that there are many adults in this country, with or without the relevant A-level qualifications, who would make excellent doctors but who, at present, have no possibility of studying medicine. For this reason the proposals for a degree course in medicine at the Open University, described in your editorial (Jan. 12, p. 54) and in the Guardian of Dec. 31, should be seriously debated. Furthermore, given a need for more medical students, the Open University could ease the cost of expanding preclinical teaching, and from a national point of view the balance of the economic arguments seems to favour the proponents of such a course. We believe that a considerable problem has to be faced in teaching the preclinical subjects by Open University methods. Practical work in anatomy and physiology, which is essential to a proper grasp of the subject, cannot be done in the student’s home, because of the need to use living or dead human material, animals, or expensive equipment. This could perhaps be met by residential courses, either in existing medical schools during vacations or eventually in a new school of the Open University, which would be appreciably longer than the customary Open University summer residential courses but would still represent a great economy. Dr Walter
Perry’s objections regarding the problems of clinical teaching are less easily dismissed. We do not think that the scheme of the Open University Society for Medical Science of using district general hospitals and postgraduate medical training centres is practicable, or would allow the University to exercise adequate control over clinical teaching. The Society exaggerates the amount of " dead " time in present full-time medical courses; if the clinical period was also part-time it is very doubtful if the whole course could be covered in 6 years. Professor Acheson (Jan. 5, p. 26) has suggested that some of the established medical schools should be asked to each take a small number of clinical students from the
Open University. This seems a much better proposition, and indeed there is an excellent precedent in the traditional practice of the London medical schools in taking students from Oxford and Cambridge. A corollary of this solution would be the need for financial support to Open University students during their period of clinical training. Since some of them will be previously earning normal adult incomes, this support would have to be generous and flexible. Perhaps the Department of Education and Science could be persuaded to provide State grants. If the Open University does consider instituting a course of this sort we suggest that it should take the opportunity to establish a degree course in human biology or human sciences, rather than’just a preclinical course. Several universities have established such courses and others are considering doing so. Of the existing courses of this type, those at Cambridge, Nottingham, and, from next October, St. Andrews, serve as preclinical courses. The latter is relevant to the Open University proposal in that their students will do their clinical studies at Manchester. Such a course would enable students wishing to take the broader type of degree, favoured by the University Grants Committee and other bodies, to do so. Those wishing to consider studying medicine would have to register as such initially and take the required options, but would not need to be finally committed before obtaining their degree in human biology. It would provide the opportunity for those aiming at medicine to meet students with a different approach during tutorial sessions, and from the Open University’s point of view would make the whole exercise more worth while.
School of Biological Sciences and School of Medicine, University of Leeds.
R. A. BAKER S. BAUMBERG M. D’A. CRAWFURD G. R. HERVEY B. E. C. NORDIN.
SIR,-Having for half a lifetime been an alert observer of the social structure from the viewpoint of a university administrator with special concern for admissions and counselling in schools, my heart was warmed by Professor Acheson’s letter (Jan. 5, p. 26) accepting with enthusiasm the idea of a medical school attached to the Open University. In the United Kingdom we have not gone in for much social planning in the past, but when it is observed that we are not able or willing, for reasons of financial or other deficiencies, to make medical training available to those who would wish to become doctors, and who would be capable of fulfilling the requirements of the course, then it would be reasonable to ask ourselves if this is the best we can do. Very large investments have been made in medical schools by the public exchequer since the 1939-45 war, and while these investments have drastically changed every aspect of the professional scene within the schools and universities, including teaching, research, and administration, there has not been a commensurate development in the size of the schools measured by the number of students-the productivity increase resulting from the expanded investment has been proportioned to increase the establishment more than the output of doctors. In these circumstances it would be realistic for society to look at the matter again in the context not only of the profession itself and its authoritative bodies, but in that of society as a whole. The Open University is supplying a social need which the existing universities declined to do, or found themselves unable to do, but it would really be a better solution to the problem if the existing medical schools would produce the revolutionary idea. 14 Osborne Gardens, Belfast BT9 6LE.
J. M. FREELAND.