- Email: [email protected]
SKIN LESIONS AS RESERVOIRS OF HOSPITAL INFECTION
483
of the problems facing the children and adults likely to come before them ". The latter might well turn out to be -especially in remoter areas-precisely those adults who are now on the Bench. The family courts would be even more likely to perpetuate present personnel, if they are " to be constituted from panels of justices selected for their capacity to deal with young persons ". The contrast here is between the declaration of intent (to evolve a treatment system staffed by trained people) and the means adopted (a reappearance of the Bench in different context, along with children’s social workers, most of whom are untrained). The main difference might well prove to be that in cases where " the facts " are in dispute, referral to the family court will mean delay, and doubts about the criteria for assessing which disputed facts matter enough for referral. In difficult and/or serious cases, in other words, the onus remains with courts virtually unchanged in personnel and powers from those it is proposed to abolish. A more honest solution would be to balance the lessened visibility of the judicial safeguards open to the offender with a veto on committal of children under 16 to treatment " away from home, except for those in care and protection, beyond control, or in need of psychiatric ...
"
assessment.
The whitepaper admits the need for something like 1000 additional social workers but nowhere suggests where they are to be recruited. Again, though it is proposed to fit Approved Schools into the " comprehensive range of residential establishments ", the change of label is unlikely to change their nature, since it is intended to preserve " the special nature " of schools provided by religious bodies and other foundations. What the Approved Schools really need is to be brought into the educational system as boarding-schools staffed and run by the Department of Education and Science. These three drawbacks will undermine a scheme which sets out to spare children the stigma of criminality ". The status of the juvenile in law would be little changed, the stigma of delinquency-if not criminality-would stick, and there would be a danger of intervention into the life of a family after the most trivial offence. The proposals in the whitepaper retain too many of the drawbacks of the status quo, and gloss over too many of the difficulties of change. This is not to say that the scheme is not capable of improvement before legislation; nor is it to prefer the present system of uncoordinated, ritualistic, and wildly unequal sentencing by juvenile courts, which range from the compassionate to the harsh with equal ignorance of the results of their labours. The proposed system positively expects cases to be followed up, viewed in a family context, and settled in agreement with the parents, and this alone is a vast improvement. "
SKIN LESIONS AS RESERVOIRS OF HOSPITAL INFECTION
two-year study carried out in a large teaching hospital in Edinburgh, Selwyn1 has discovered that patients with chronic skin diseases such as psoriasis and eczema apparently provide excellent breeding-grounds for the ubiquitous golden staphylococcus and the gramnegative coliform bacilli which are almost as common in the hospital environment. Using the slit-sampler and settle-plates in the main skin wards, he found counts of Staphylococcus aureus of 10-20 per 10 c. ft. (100-200 times IN
a
1.
Selwyn, S. J. Hyg., Camb. 1965, 63, 59.
greater than might be expected in an ordinary hospital ward); the counts in the bathrooms (using settle-plates
only)
were
considerably higher. Bedding, baths, fomites,
and ward dust all yielded heavy growths of the prevalent pathogens. The baths seemed to favour Pseudomonas pyocyanea, perhaps owing to the use of cetrimide as a cleanser, though later disinfection of the baths with a hypochlorite-detergent solution seemed to make no impression on the gross environmental contamination. The hospital bath as a bacterial depot obviously needs closer scrutiny. It seemed logical to suspect the skin lesions as the main reservoir of infection. Eczema and psoriasis were the two commonest skin diseases, and 45% of 342 patients were found to have lesions which were significantly infected on admission; about 50%o of patients acquired primary whilst in hospital. infection or Staph. aureus was the commonest pathogen, and phage-typing and antibiograms were used to demonstrate sources and spread of infection. Autogenous infection from nasal carriage occurred in a relatively small proportion of cases. The incidence of infection with gram-negative bacilli was highest in the third most frequent diagnostic groupvaricose eczema with ulceration. Despite the high incidence of bacteriologically infected chronic lesions, only 20% were judged to be clinically infected on admission; only 18% of acquired hospital infections were clinically obvious, and these were mostly in eczema cases.2 Airsamples from the environment of individual patients in a specially designed cubicle indicated that epithelial squames constituted a large part of the bacteria-carrying particles; evidence from the rate of deposition of these airborne particles and the use of a size-grading sampler showed that psoriasis patients disperse mostly larger particles (over 18{.L) and eczema patients mostly smaller particles (4-18). The psoriasis patient is a particularly
superinfection
prolific disperser. In attempts to control the spread of infection, Selwyn used framycetin nebulisers for nasal disinfection, and cleansed and disinfected the baths according to the method of Boycott 3; he treated the skin lesions with the’Rickerspray Antibiotic’ (neomycin, bacitracin, and colistin sulphate). By ringing the changes with the last of these treatments in male and female wards, he showed conclusively that skin-disinfection alone greatly reduced the level of environmental contamination with the skin pathogens and almost eliminated cross-infection of the skin lesions. Nasal disinfection, in itself effective, obviated the risk of autogenous infection but made no impression on the level of environmental contamination or the incidence of cross-infection. Despite regular hand-washing, hand carriage (but not nose carriage) of the prevalent pathogens was common and heavy among the nursing staff. The work of Duguid and Wallace 4 on the dispersal of bacteria-carrying particles from the healthy skin during movement and the hazard of aggravating this dispersal by theatre rituals, including showering, have led to a search for impervious garments for theatre staff, exemplified by the studies of Dr. Bernard and his colleagues reported on an earlier page of this issue. The hazard of infection from the healthy skin of the surgeon, however, seems small compared with the risk of introducing a patient with psoriasis or eczema into a general hospital ward. These patients should be isolated until their lesions have been 2. 3. 4.
Selwyn, S., Chalmers, D. Br. J. Derm. 1965, 77, 349. Boycott, J. A. Lancet, 1956, ii, 678. Duguid, J P., Wallace, A T. ibid, 1948, ii, 845.
484 In any event, of the lesion should be maintained stay in hospital.
bacteriologically screened. treatment
patient’s
antiseptic during the
FROM MICE TO MEN
IN his Bradshaw Lecture of 1910 Sir Alfred Pearce Gouldsaid: Many years ago I showed a patient at a meeting of the Clinical Society of London who recovered spontaneously and completely when she seemed to be at death’s door from cancerous deposits in the lungs and the neck of the femur, secondary to cancer of the breast." Pearce Gould’s experience was not unique. Not long after, Rohdenbergrecorded 302 cases in which complete or partial recession of malignant growths had been reported. A large proportion of these did not stand up to careful scrutiny, but a significant group of fully substantiated In 1959, after rigorous exclusion of cases remained. doubtful original assessments, Everson and Cole3 sifted out 112 cases since 1900 which were adequately documented and acceptable examples of regression in primary and secondary malignant disease. The patients had all had conventional forms of treatment. In some (as in Pearce Gould’s patient) the treatment could scarcely have brought about the regression. As an instance, in 1918 Paterson4 operated on a patient with cancer of the stomach. There were secondary deposits in the liver, and biopsy "
of a
lymph-node revealed that it had undergone malignant
transformation.
The abdominal wound
was
closed.
Eighteen years later the patient was " quite well ". In some patients, treatment probably played some part. Rankin et a1.,5 for example, describe a patient with familial polyposis of the colon and hepatic metastases (microscopically confirmed) from a rectal cancer. The patient survived ten years after undergoing abdominoperineal resection and proctosigmoidectomy. At this time a further operation, carried out for removal of a cancer in the remaining colon, disclosed that the liver metastases observed ten years earlier had disappeared. There are two ways of looking at these reports. On the one hand, one may regard them as occasional aberrations, on a par with telepathy and other bizarre manifestations of extrasensory perception, and, as such, of little relevance to everyday experience. Yet a moment’s thought will show that regression in malignant disease is far from being rare. How else can we explain the commonly observed fluctuations in the rate of growth in malignant tumours ? Survival-rates in cancer of individual organs differ widely from patient to patient, to the despair of diligent collectors of statistics. The invocation of the magic words " biological control " does not get us much further in explaining what happens in these patients. On the other hand, one may take the view of Pearce Gould 1: "
My present purpose is not to vaunt a remedy but to state a fact-that cancer, even when advanced in degree and of long duration, may get better, and does sometimes get well. There is cure of cancer, apart from operative removal... you may say to me: there is little comfort in all this ... you tantalise by a record of very rare exceptions in the grey, grim drama of cancer. Not so. These cases, rare though they be, are the sun of our
hope." Cancer research has
passed through
various
phases
1. Pearce Gould, A. Lancet, 1910, ii, 1665. 2. Rohdenburg, G. L. J. Cancer Res. 1918, 3, 255. 3. Everson, T. C., Cole, W. H. J. Am. med. Ass. 1959, 169, 1758. 4. Paterson, P. Lancet, 1936, i, 1402. 5 Rankin, G. B., Brown, C. H., Crile, G., Jr. Ann. Surg. 1965, 162, 156.
since Pearce Gould’s day. For some time it has mostly taken the form of experimental work (predominantly on rats, mice, and guineapigs) designed to advance our knowledge of carcinogenesis and the effects of radiation and of antineoplastic drugs. A new phase, extending the earlier work of Warburg, is the study of the isoenzyme patterns in human tumours, which has been made possible by the elaboration of laboratory techniques such as gel electrophoresis on minute pieces of tissue. An advance from investigating the biochemical changes induced by cancer in animals and in isolated tissues (and indeed cells) in man towards investigating the changes in the whole patient throughout the course of the disease seems logical. It is in this context that so-called " spontaneous " (unexplained) regression is highly relevant. As and when regression becomes apparent in patients they should be subjected to constant surveillance. There could be profit in turning from mice to men. DEVELOPMENT OF HEALTH
THE Netherlands Universities Foundation for International Cooperation and the Belgian office for Development Cooperation announce two further international courses in health development, at Amsterdam in 1966 and at Antwerp in 1967.* The courses, sponsored jointly by these two organisations and the Netherlands and Belgian institutes of tropical medicine, are open to medical, veterinary, or biological graduates who work or intend to work in developing countries. During five months, starting each year on Feb. 1, formal instruction will be given in the economic and social aspects of development, the development of health services, and tropical medicine and hygiene. For the first time, candidates who pass the examination at the end of this course may proceed to a further four months’ research and group study, at the end of which they may submit dissertations for the diploma of international public health. Each course will be divided into two sections, one English-speaking and the other Frenchspeaking. A guiding principle of this venture is that, on the one hand, clinicians in the rapidly changing environment of a developing country should be well versed in all aspects of public health, and, on the other hand, publichealth workers should know something of clinical medicine. In the two courses that have already been held, doctors from 24 countries have been able to profit by Dutch and Belgian knowledge of tropical health. The combination of economics and sociology with preventive and clinical medicine is imaginative. British schools of tropical medicine draw from a wider experience of the tropics than any others. The Ministry of Overseas Development proposes1 to establish an Institute of Development Studies, which will be concerned with the kind of problems that the non-medical parts of these healthdevelopment courses are designed to tackle. When in October the Commonwealth Medical Conference comes to discuss ways for Britain to help promote health in the developing countries, it could well consider what is to be learnt from our neighbours’ experiment. Between them, our schools of tropical medicine and the new Institute could offer, along similar lines, a service second to none. inquiries should be addressed to NUFFIc, 27, Molenstraat, The Hague, or to The Belgian Office for Development Cooperation, 55, Guldenvlieslaan, Brussels. The fee for the course is s4,)()
1. See
Lancet, August 14, p. 329.
of the problems facing the children and adults likely to come before them ". The latter might well turn out to be -especially in remoter areas-precisely those adults who are now on the Bench. The family courts would be even more likely to perpetuate present personnel, if they are " to be constituted from panels of justices selected for their capacity to deal with young persons ". The contrast here is between the declaration of intent (to evolve a treatment system staffed by trained people) and the means adopted (a reappearance of the Bench in different context, along with children’s social workers, most of whom are untrained). The main difference might well prove to be that in cases where " the facts " are in dispute, referral to the family court will mean delay, and doubts about the criteria for assessing which disputed facts matter enough for referral. In difficult and/or serious cases, in other words, the onus remains with courts virtually unchanged in personnel and powers from those it is proposed to abolish. A more honest solution would be to balance the lessened visibility of the judicial safeguards open to the offender with a veto on committal of children under 16 to treatment " away from home, except for those in care and protection, beyond control, or in need of psychiatric ...
"
assessment.
The whitepaper admits the need for something like 1000 additional social workers but nowhere suggests where they are to be recruited. Again, though it is proposed to fit Approved Schools into the " comprehensive range of residential establishments ", the change of label is unlikely to change their nature, since it is intended to preserve " the special nature " of schools provided by religious bodies and other foundations. What the Approved Schools really need is to be brought into the educational system as boarding-schools staffed and run by the Department of Education and Science. These three drawbacks will undermine a scheme which sets out to spare children the stigma of criminality ". The status of the juvenile in law would be little changed, the stigma of delinquency-if not criminality-would stick, and there would be a danger of intervention into the life of a family after the most trivial offence. The proposals in the whitepaper retain too many of the drawbacks of the status quo, and gloss over too many of the difficulties of change. This is not to say that the scheme is not capable of improvement before legislation; nor is it to prefer the present system of uncoordinated, ritualistic, and wildly unequal sentencing by juvenile courts, which range from the compassionate to the harsh with equal ignorance of the results of their labours. The proposed system positively expects cases to be followed up, viewed in a family context, and settled in agreement with the parents, and this alone is a vast improvement. "
SKIN LESIONS AS RESERVOIRS OF HOSPITAL INFECTION
two-year study carried out in a large teaching hospital in Edinburgh, Selwyn1 has discovered that patients with chronic skin diseases such as psoriasis and eczema apparently provide excellent breeding-grounds for the ubiquitous golden staphylococcus and the gramnegative coliform bacilli which are almost as common in the hospital environment. Using the slit-sampler and settle-plates in the main skin wards, he found counts of Staphylococcus aureus of 10-20 per 10 c. ft. (100-200 times IN
a
1.
Selwyn, S. J. Hyg., Camb. 1965, 63, 59.
greater than might be expected in an ordinary hospital ward); the counts in the bathrooms (using settle-plates
only)
were
considerably higher. Bedding, baths, fomites,
and ward dust all yielded heavy growths of the prevalent pathogens. The baths seemed to favour Pseudomonas pyocyanea, perhaps owing to the use of cetrimide as a cleanser, though later disinfection of the baths with a hypochlorite-detergent solution seemed to make no impression on the gross environmental contamination. The hospital bath as a bacterial depot obviously needs closer scrutiny. It seemed logical to suspect the skin lesions as the main reservoir of infection. Eczema and psoriasis were the two commonest skin diseases, and 45% of 342 patients were found to have lesions which were significantly infected on admission; about 50%o of patients acquired primary whilst in hospital. infection or Staph. aureus was the commonest pathogen, and phage-typing and antibiograms were used to demonstrate sources and spread of infection. Autogenous infection from nasal carriage occurred in a relatively small proportion of cases. The incidence of infection with gram-negative bacilli was highest in the third most frequent diagnostic groupvaricose eczema with ulceration. Despite the high incidence of bacteriologically infected chronic lesions, only 20% were judged to be clinically infected on admission; only 18% of acquired hospital infections were clinically obvious, and these were mostly in eczema cases.2 Airsamples from the environment of individual patients in a specially designed cubicle indicated that epithelial squames constituted a large part of the bacteria-carrying particles; evidence from the rate of deposition of these airborne particles and the use of a size-grading sampler showed that psoriasis patients disperse mostly larger particles (over 18{.L) and eczema patients mostly smaller particles (4-18). The psoriasis patient is a particularly
superinfection
prolific disperser. In attempts to control the spread of infection, Selwyn used framycetin nebulisers for nasal disinfection, and cleansed and disinfected the baths according to the method of Boycott 3; he treated the skin lesions with the’Rickerspray Antibiotic’ (neomycin, bacitracin, and colistin sulphate). By ringing the changes with the last of these treatments in male and female wards, he showed conclusively that skin-disinfection alone greatly reduced the level of environmental contamination with the skin pathogens and almost eliminated cross-infection of the skin lesions. Nasal disinfection, in itself effective, obviated the risk of autogenous infection but made no impression on the level of environmental contamination or the incidence of cross-infection. Despite regular hand-washing, hand carriage (but not nose carriage) of the prevalent pathogens was common and heavy among the nursing staff. The work of Duguid and Wallace 4 on the dispersal of bacteria-carrying particles from the healthy skin during movement and the hazard of aggravating this dispersal by theatre rituals, including showering, have led to a search for impervious garments for theatre staff, exemplified by the studies of Dr. Bernard and his colleagues reported on an earlier page of this issue. The hazard of infection from the healthy skin of the surgeon, however, seems small compared with the risk of introducing a patient with psoriasis or eczema into a general hospital ward. These patients should be isolated until their lesions have been 2. 3. 4.
Selwyn, S., Chalmers, D. Br. J. Derm. 1965, 77, 349. Boycott, J. A. Lancet, 1956, ii, 678. Duguid, J P., Wallace, A T. ibid, 1948, ii, 845.
484 In any event, of the lesion should be maintained stay in hospital.
bacteriologically screened. treatment
patient’s
antiseptic during the
FROM MICE TO MEN
IN his Bradshaw Lecture of 1910 Sir Alfred Pearce Gouldsaid: Many years ago I showed a patient at a meeting of the Clinical Society of London who recovered spontaneously and completely when she seemed to be at death’s door from cancerous deposits in the lungs and the neck of the femur, secondary to cancer of the breast." Pearce Gould’s experience was not unique. Not long after, Rohdenbergrecorded 302 cases in which complete or partial recession of malignant growths had been reported. A large proportion of these did not stand up to careful scrutiny, but a significant group of fully substantiated In 1959, after rigorous exclusion of cases remained. doubtful original assessments, Everson and Cole3 sifted out 112 cases since 1900 which were adequately documented and acceptable examples of regression in primary and secondary malignant disease. The patients had all had conventional forms of treatment. In some (as in Pearce Gould’s patient) the treatment could scarcely have brought about the regression. As an instance, in 1918 Paterson4 operated on a patient with cancer of the stomach. There were secondary deposits in the liver, and biopsy "
of a
lymph-node revealed that it had undergone malignant
transformation.
The abdominal wound
was
closed.
Eighteen years later the patient was " quite well ". In some patients, treatment probably played some part. Rankin et a1.,5 for example, describe a patient with familial polyposis of the colon and hepatic metastases (microscopically confirmed) from a rectal cancer. The patient survived ten years after undergoing abdominoperineal resection and proctosigmoidectomy. At this time a further operation, carried out for removal of a cancer in the remaining colon, disclosed that the liver metastases observed ten years earlier had disappeared. There are two ways of looking at these reports. On the one hand, one may regard them as occasional aberrations, on a par with telepathy and other bizarre manifestations of extrasensory perception, and, as such, of little relevance to everyday experience. Yet a moment’s thought will show that regression in malignant disease is far from being rare. How else can we explain the commonly observed fluctuations in the rate of growth in malignant tumours ? Survival-rates in cancer of individual organs differ widely from patient to patient, to the despair of diligent collectors of statistics. The invocation of the magic words " biological control " does not get us much further in explaining what happens in these patients. On the other hand, one may take the view of Pearce Gould 1: "
My present purpose is not to vaunt a remedy but to state a fact-that cancer, even when advanced in degree and of long duration, may get better, and does sometimes get well. There is cure of cancer, apart from operative removal... you may say to me: there is little comfort in all this ... you tantalise by a record of very rare exceptions in the grey, grim drama of cancer. Not so. These cases, rare though they be, are the sun of our
hope." Cancer research has
passed through
various
phases
1. Pearce Gould, A. Lancet, 1910, ii, 1665. 2. Rohdenburg, G. L. J. Cancer Res. 1918, 3, 255. 3. Everson, T. C., Cole, W. H. J. Am. med. Ass. 1959, 169, 1758. 4. Paterson, P. Lancet, 1936, i, 1402. 5 Rankin, G. B., Brown, C. H., Crile, G., Jr. Ann. Surg. 1965, 162, 156.
since Pearce Gould’s day. For some time it has mostly taken the form of experimental work (predominantly on rats, mice, and guineapigs) designed to advance our knowledge of carcinogenesis and the effects of radiation and of antineoplastic drugs. A new phase, extending the earlier work of Warburg, is the study of the isoenzyme patterns in human tumours, which has been made possible by the elaboration of laboratory techniques such as gel electrophoresis on minute pieces of tissue. An advance from investigating the biochemical changes induced by cancer in animals and in isolated tissues (and indeed cells) in man towards investigating the changes in the whole patient throughout the course of the disease seems logical. It is in this context that so-called " spontaneous " (unexplained) regression is highly relevant. As and when regression becomes apparent in patients they should be subjected to constant surveillance. There could be profit in turning from mice to men. DEVELOPMENT OF HEALTH
THE Netherlands Universities Foundation for International Cooperation and the Belgian office for Development Cooperation announce two further international courses in health development, at Amsterdam in 1966 and at Antwerp in 1967.* The courses, sponsored jointly by these two organisations and the Netherlands and Belgian institutes of tropical medicine, are open to medical, veterinary, or biological graduates who work or intend to work in developing countries. During five months, starting each year on Feb. 1, formal instruction will be given in the economic and social aspects of development, the development of health services, and tropical medicine and hygiene. For the first time, candidates who pass the examination at the end of this course may proceed to a further four months’ research and group study, at the end of which they may submit dissertations for the diploma of international public health. Each course will be divided into two sections, one English-speaking and the other Frenchspeaking. A guiding principle of this venture is that, on the one hand, clinicians in the rapidly changing environment of a developing country should be well versed in all aspects of public health, and, on the other hand, publichealth workers should know something of clinical medicine. In the two courses that have already been held, doctors from 24 countries have been able to profit by Dutch and Belgian knowledge of tropical health. The combination of economics and sociology with preventive and clinical medicine is imaginative. British schools of tropical medicine draw from a wider experience of the tropics than any others. The Ministry of Overseas Development proposes1 to establish an Institute of Development Studies, which will be concerned with the kind of problems that the non-medical parts of these healthdevelopment courses are designed to tackle. When in October the Commonwealth Medical Conference comes to discuss ways for Britain to help promote health in the developing countries, it could well consider what is to be learnt from our neighbours’ experiment. Between them, our schools of tropical medicine and the new Institute could offer, along similar lines, a service second to none. inquiries should be addressed to NUFFIc, 27, Molenstraat, The Hague, or to The Belgian Office for Development Cooperation, 55, Guldenvlieslaan, Brussels. The fee for the course is s4,)()
1. See
Lancet, August 14, p. 329.