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STAPHYLOCOCCI OUTSIDE HOSPITALS
1154
ionised-calcium fraction
might be depressed the results consistently good, and they found that estimation of the dose was difficult and overdosage dangerous. were
not
In most circumstances, as FIRT and HEJHAL suggest, the risk of citrate poisoning is small; but it should be clearly borne in mind whenever a large volume of citrated blood is. transfused rapidly, and especially when there is a disappointing response to apparently adequate replacement. It is particularly likely to develop during massive transfusions in patients with severe liver disease or interference with normal hepatic circulation, and during operations on the heart and great vessels, especially when the whole body is cooled. Apart from packed red cells, most of the alternatives to citrated whole blood which have been suggested, such as red cells suspended in dextran or gelatin, or decalcified blood, are objectionable-usually because of the amount of manipulation involved and the great risk of infection. Awareness of the risk of citrate poisoning should go far to reduce deaths from this cause, but in addition there should be a wider recognition of the risks of blood-transfusion : the sooner bleeding is stopped, the smaller is the amount of blood that has to be transfused.
Annotations STAPHYLOCOCCI OUTSIDE HOSPITALS IN hospitals penicillin is still often used, and there is a fair prospect of its doing good if the infecting organism is penicillin-sensitive-for example, meningococcus, gonococcus, pneumococcus, or hsemolytic streptococcus. A staphylococcus infection acquired outside hospital is likely to be due to a penicillin-sensitive organism, whereas a staphylococcus infection acquired inside hospital is much more likely to be due to a penicillinase-producing, penicillin-resistant organism. This is because penicillin is too often given in hospital as a placebo, as a treatment for undiagnosed infections, as a substitute for a reliable technique of asepsis, and in the treatment of minor infections which would quickly resolve without its use. Because penicillin is so widely administered within their walls, hospitals are often visited by what has been called a staphylococcus plague.! The dangers that are thus forced on patients in hospital have been repeatedly stressed in our columns. The simple explanation of the staphylococcus plague is that, in hospitals where much penicillin is given, penicillin-resistant strains of staphylococci replace the sensitive ones. It now seems necessary to note the danger that may arise from the spread of penicillin-resistant staphylococci from hospital to the general community. The danger is real. About 14-18% of healthy adults now carry penicillin-resistant staphylococci in their noses,2compared with some 6% in 1954.3 Recent investigations emphasise the important part that may be played by maternity hospitals in the spread of this kind of infection. Hutchison and Bowman4 examined events in a maternity hospital for thirteen weeks. From 3542 swabs from infants, mothers, hospital staff, and dust they isolated 2260 strains of Staphylococcus aureus, which were examined for antibiotic sensitivity and by phage-typing. Staphylococci isolated from mothers on admission to hospital were 86% penicillin-sensitive and 14% penicillin-resistant. Staphylococci from mothers dis1. Lancet, 1957, i, 723. 2. Fusillo, M. H., Roerig, R. N., Ernst, K. F. Antibiot. Chemother. 1954, 4, 1202. 3. Rountree, P. M., Rheuben, J. Med. J. Aust. 1956, i, 399. 4. Hutchison, J. G. P., Bowman, W. D. Acta pœdiat., Stockh. 1957, 46, 125.
from the lying-in wards were 40% penicillinsensitive and 60% penicillin -resistant-a notable change. Women discharged from the antenatal ward showed no such change. Thus there is a real risk of spread of penicillin-resistant staphylococci from hospitals to the general population.But the risk may not be quite so great as it seems at first. Hutchison and Bowman continued investigations on 28 women who were discharged from hospital carrying easily identifiable strains of Staph. aureus. Six weeks later, of 18 examined 7 were carrying hospital strains, 5 were no longer carriers, and 6 carried nonhospital types. Six months later 2 out of 10 women were carrying the hospital type but their infants were not; one infant carried a hospital type no longer found in its mother’s nose. There was some evidence that resistant hospital strains might revert to sensitivity in the home environment. The same problem was investigated by Hurst.s She found that 99% of 106 babies born in hospitals harboured coagulase-positive Staph. aureus by the time they left the hospital nursery. When the strains of 34 of these infants were examined in detail, it was found that 33 (97%) of the babies carried at least one penicillinresistant strain. At least half of the infants who were followed continued to carry hospital staphylococci at the end of their first year of life, the organisms being found for a longer period in the throats than in the noses. The inference is that the staphylococci acquired at birth may prevent new strains of staphylococci from becoming established later. This may explain why hospital-born babies tend to retain their antibiotic-resistant hospital staphylococci longer than their mothers. Since the staphylococci are carried in the throat, and since babies’ saliva is widely distributed, babies born in hospital are a potentially important source of antibiotic-resistant staphylococci distributed to the general public. Of 36 babies born at home 72% acquired staphylococci in their noses and throats within the first two weeks of life, but only 18% acquired penicillin-resistant strains. There was no evidence that the penicillin-sensitive strains acquired at home were carried for shorter periods than the penicillin-resistant hospital strains. Babies that did not acquire Staph. aureus in the first fortnight either acquired it in the throat alone or were non-carriers. Apparently babies who do not become carriers of staphylococci in the first two months of life are unlikely to become carriers later. Meanwhile, Dr. Gould and Dr. Cruikshank, whose article appears in a later part of this issue, have examined the epidemiology of staphylococcal infection in a nonindustrial urban general practice. Among 300 patients without staphylococcal lesions, 33% were nasal carriers of staphylococci, and 84% of the carried strains were penicillin-sensitive. 5% of the patients in the practice had one or more superficial staphylococcal infections each year. 95% of the lesions responded to simple local treatment and the remainder to systemic penicillin therapy. The best way of preventing recurrence of infection, which is so common and so distressing, appears to be to administer an antibacterial cream to the nose for one week out of four. To reduce the risk of sensitising patients and producing antibiotic-resistant staphylococci, Gould and Cruikshank used a cream containing chlorhexidine (’Hibitane’) (0-5%) with neomycin sulphate (0-5%) or bacitracin (2000 units per g.). This proved to be effective and non-irritant in the dosage recommended.
charged
PROFILE BY PULHESTIB profilesare familiar to most doctors who have served in the Forces. Holt,7 seeking to classify the
PULHEEMS
functional disabilities of handicapped children, suggests a modification of PuLHEBMS called PULHESTIB. Each 5. Hurst, V. J. Hyg., Camb. 1957, 55, 299, 313. 6. Fletcher, R. T. Brit. med. J. 1949, i, 83. 7. Holt, K. S. Arch. Dis. Childh. 1957, 32, 226.
1155 letter stands for a section of the profile : p for general physique. u for upper limbs, L for the lower limbs and locomotion, H for hearing, E for eyes, s for speech, " T tor toilet." I for intelligence, and B for behaviour. Abilities under each section are rated on a four-point scale.1 meaning full ability and 4 meaning no ability. Children with one handicap often have others ; thus a spastic child may also be epileptic and mentally retarded and have a behaviour disorder. Medical and social workers trained to help with one of these handicaps may neglect the others. A classification by lesions or by physical signs is often deceptive. Thus the group " deaf " includes some children whose intellectual defect makes training in a school for the deaf quite impossible. A classification based on the functional abilities of many organs helps to keep the whole child in view. Profiles by PULHESTIB are welcome, but must we have such an ugly name? Dr. Holt should find a more euphonious anagram. PHUTrLEBS trips well but sounds discouraging. But LUPHIBEST is sonorous and indeed might pass as a proper name. CAVAL INFUSION IN THE TREATMENT OF ACUTE RENAL FAILURE
THE
2
principles of conservative treatment of anuria 1 widely agreed in this country. When the illness is mild the patient can be fed orally on lactose and water 3a regimen that can be tolerated for two weeks or even longer. In more severe cases it may be necessary to resort to intragastric tube-feeding 1, though the originators of the method use it much less often now4 and prefer are
caval infusion after catheterisation 5-8. Chambers and Smith9 have lately described their experience of this technique. In one of the Glasgow hospital sectors, which has more than 3000 beds, these workers have since 1950 encountered 29 patients with acute renal failure, of whom 8 needed caval catheterisation. They have also applied this technique to 2 cases in which severe postoperative illness and intestinal obstruction necessitated long-continued intravenous therapy. They use a nylon cardiac catheter (no. 9F) inserted into the right femoral vein via a cut-down on the great saphenous vein at its upper end. The catheter is so placed that its tip lies just below the entry of the inferior vena cava into the right atrium, and the hypertonic infusion is diluted by the largest possible blood-flow. Chambers and Smith emphasise that flow through the catheter must be continuous, and they place a Y-piece in the rubber-tubing so that a second reservoir of fluid is available when the first is being replenished. Heparin (1000 units per 500 ml.) is added to the infusion. Of 10 patients so treated for periods of four to twenty-five days, 6 survived and 4 died. It is thought that the 6 surviving patients owed their lives to caval therapy, and that such therapy did not contribute in any way to the deaths (though necropsy was carried out in only 2 of the 4 fatal cases). Death was delayed for remarkably long periods in inevitably fatal cases. There was no wound sepsis at the site of catheter insertion, no pulmonary embolism, and no trouble in withdrawing the catheter at the cessation of treatment. There was no need of an artificial kidney in this series. Caval catheterisation has not been universally accepted, and Taylor 10, in cases of acute renal failure following 1. Bull, G. M., Joekes, A. M., Lowe, K. G. Lancet, 1949, ii, 229. 2. Evans, B. M., Hughes-Jones, N. C., Milne, M. D., Yellowlees, H. ibid. 1953, ii, 791. 3. Oard, H. C., Walker, G. I. Jr. Amer. J. Med. 1955, 18, 199. 4. Bull, G. M., Joekes, A. M., Lowe, K. G. Lancet, 1955, ii, 1152. 5. De Keyser, R., Van Eeckhoutte, P., Kop, P. S. M., Kolff, W. J. Ned. Tijdschr. Geneesk. 1949, 93, 2386. 6. Russell, C. S., Dewhurst, C. J., Brace, J. C. Lancet, 1954, i, 902. 7. Shaw, G., Mair, J. ibid. p. 1031. 8. Chalmers, J. A., Fawns, H. T. ibid. 1955, i, 79. 9. Chambers, J. W., Smith, G. Brit. J. Surg. 1957, 45, 160. 10. Taylor, W. H. Lancet. Oct. 12, 1957. p. 703.
head injury and surgical operation, has largely abandoned it in favour of infusing 5-20°° glucose solution through a polyethylene catheter inserted several inches into a vein. Publication of further series of cases of acute renal failure treated by caval catheterisation would help to define its real value in this condition.
peripheral
FIVE YEARS OLD
FROM its foundation the College of General Practitioners. which was five vears old on Nov. 19, has set much store by its faculties and peripheral councils ; and with new councils in Australia and New Zealand, and an active faculty in Kenya, its influence is spreading far faculties in all ; twentyafield. There are now two of these are in the United Kingdom and the remainder overseas. The faculties give elasticity to the College, for they enable its activities to be adjusted to local conditions, particularly in undergraduate education, postgraduate education, and research. (In Canada the College of General Practice is firmly established, and shares the same ideals.) But the expansion of the College has not been wholly at the periphery ; increasing demands on the centre have made it necessary to move the College office to more spacious accommodation. The fifth annual report shows that there has been further extension of the work of the three main committees of council. The undergraduate who qualifies without having had personal experience of good general practice will soon be the exception, and educational activities in every faculty ensure that members and associates can honour their obligation to undertake postgraduate study. Here again much of the success achieved has been due to the efficient working of the faculty system. The research committee has had the support of a research register of increasing size and value. College investigations, both large and small, are in progress, some in collaboration with other research bodies. A College records unit is to be established to undertake the continued study of morbidity in general practice. This work, together with the coordination of the research of the councils and faculties, throws a heavy strain on the financial and personal resources of the College, and the limit of voluntary endeavour has almost been reached. In the spiritual sense, the College makes steady progress. It has examined itself and studied its own criteria for entrance and continued membership. No doubt these will become stricter. It remains true to the academic standard which it has set for itself.
thirty-five
STERILISING SYRINGES BY RADIATION THE demand for sterile syringes and needles is becoming so great that more and more hospitals are considering the advisability of starting a central syringe service. How widely the demand for syringes varies between different hospitals has been shown by Murphy,l who chose an area of East Anglia containing hospitals of all types and took a census of injections for a week. At one end of the scale a general (acute) hospital with only 16-1% of the total beds accounted for 56-7% of all injections, while at the other end a mental hospital with 44-9% of the total beds accounted for only 9-0% of the injections. Opinions have differed on the best methods of sterilising syringes and needles ; and some hospitals still use the autoclave for this purpose, despite the Medical Research Council’s insistence2 that hot-air sterilisation is best. Grave theoretical objections to autoclaves for sterilising assembled syringes have been raised by Darmady and Hughes,33 who point out that it is difficult for steam to penetrate between the plunger and barrel of an assembled syringe, 1. Murphy, E. C. Mon. Bull. Min. Hlth Lab. Serv. 1957, 16, 212. 2. The Sterilisation, Use and Care of Syringes. Medical Research Council War Memorandum no. 15. H.M. Stationery Office, 1945. 3. Darmady, E. M., Hughes, K. E. Lancet, 1955, i, 513.
ionised-calcium fraction
might be depressed the results consistently good, and they found that estimation of the dose was difficult and overdosage dangerous. were
not
In most circumstances, as FIRT and HEJHAL suggest, the risk of citrate poisoning is small; but it should be clearly borne in mind whenever a large volume of citrated blood is. transfused rapidly, and especially when there is a disappointing response to apparently adequate replacement. It is particularly likely to develop during massive transfusions in patients with severe liver disease or interference with normal hepatic circulation, and during operations on the heart and great vessels, especially when the whole body is cooled. Apart from packed red cells, most of the alternatives to citrated whole blood which have been suggested, such as red cells suspended in dextran or gelatin, or decalcified blood, are objectionable-usually because of the amount of manipulation involved and the great risk of infection. Awareness of the risk of citrate poisoning should go far to reduce deaths from this cause, but in addition there should be a wider recognition of the risks of blood-transfusion : the sooner bleeding is stopped, the smaller is the amount of blood that has to be transfused.
Annotations STAPHYLOCOCCI OUTSIDE HOSPITALS IN hospitals penicillin is still often used, and there is a fair prospect of its doing good if the infecting organism is penicillin-sensitive-for example, meningococcus, gonococcus, pneumococcus, or hsemolytic streptococcus. A staphylococcus infection acquired outside hospital is likely to be due to a penicillin-sensitive organism, whereas a staphylococcus infection acquired inside hospital is much more likely to be due to a penicillinase-producing, penicillin-resistant organism. This is because penicillin is too often given in hospital as a placebo, as a treatment for undiagnosed infections, as a substitute for a reliable technique of asepsis, and in the treatment of minor infections which would quickly resolve without its use. Because penicillin is so widely administered within their walls, hospitals are often visited by what has been called a staphylococcus plague.! The dangers that are thus forced on patients in hospital have been repeatedly stressed in our columns. The simple explanation of the staphylococcus plague is that, in hospitals where much penicillin is given, penicillin-resistant strains of staphylococci replace the sensitive ones. It now seems necessary to note the danger that may arise from the spread of penicillin-resistant staphylococci from hospital to the general community. The danger is real. About 14-18% of healthy adults now carry penicillin-resistant staphylococci in their noses,2compared with some 6% in 1954.3 Recent investigations emphasise the important part that may be played by maternity hospitals in the spread of this kind of infection. Hutchison and Bowman4 examined events in a maternity hospital for thirteen weeks. From 3542 swabs from infants, mothers, hospital staff, and dust they isolated 2260 strains of Staphylococcus aureus, which were examined for antibiotic sensitivity and by phage-typing. Staphylococci isolated from mothers on admission to hospital were 86% penicillin-sensitive and 14% penicillin-resistant. Staphylococci from mothers dis1. Lancet, 1957, i, 723. 2. Fusillo, M. H., Roerig, R. N., Ernst, K. F. Antibiot. Chemother. 1954, 4, 1202. 3. Rountree, P. M., Rheuben, J. Med. J. Aust. 1956, i, 399. 4. Hutchison, J. G. P., Bowman, W. D. Acta pœdiat., Stockh. 1957, 46, 125.
from the lying-in wards were 40% penicillinsensitive and 60% penicillin -resistant-a notable change. Women discharged from the antenatal ward showed no such change. Thus there is a real risk of spread of penicillin-resistant staphylococci from hospitals to the general population.But the risk may not be quite so great as it seems at first. Hutchison and Bowman continued investigations on 28 women who were discharged from hospital carrying easily identifiable strains of Staph. aureus. Six weeks later, of 18 examined 7 were carrying hospital strains, 5 were no longer carriers, and 6 carried nonhospital types. Six months later 2 out of 10 women were carrying the hospital type but their infants were not; one infant carried a hospital type no longer found in its mother’s nose. There was some evidence that resistant hospital strains might revert to sensitivity in the home environment. The same problem was investigated by Hurst.s She found that 99% of 106 babies born in hospitals harboured coagulase-positive Staph. aureus by the time they left the hospital nursery. When the strains of 34 of these infants were examined in detail, it was found that 33 (97%) of the babies carried at least one penicillinresistant strain. At least half of the infants who were followed continued to carry hospital staphylococci at the end of their first year of life, the organisms being found for a longer period in the throats than in the noses. The inference is that the staphylococci acquired at birth may prevent new strains of staphylococci from becoming established later. This may explain why hospital-born babies tend to retain their antibiotic-resistant hospital staphylococci longer than their mothers. Since the staphylococci are carried in the throat, and since babies’ saliva is widely distributed, babies born in hospital are a potentially important source of antibiotic-resistant staphylococci distributed to the general public. Of 36 babies born at home 72% acquired staphylococci in their noses and throats within the first two weeks of life, but only 18% acquired penicillin-resistant strains. There was no evidence that the penicillin-sensitive strains acquired at home were carried for shorter periods than the penicillin-resistant hospital strains. Babies that did not acquire Staph. aureus in the first fortnight either acquired it in the throat alone or were non-carriers. Apparently babies who do not become carriers of staphylococci in the first two months of life are unlikely to become carriers later. Meanwhile, Dr. Gould and Dr. Cruikshank, whose article appears in a later part of this issue, have examined the epidemiology of staphylococcal infection in a nonindustrial urban general practice. Among 300 patients without staphylococcal lesions, 33% were nasal carriers of staphylococci, and 84% of the carried strains were penicillin-sensitive. 5% of the patients in the practice had one or more superficial staphylococcal infections each year. 95% of the lesions responded to simple local treatment and the remainder to systemic penicillin therapy. The best way of preventing recurrence of infection, which is so common and so distressing, appears to be to administer an antibacterial cream to the nose for one week out of four. To reduce the risk of sensitising patients and producing antibiotic-resistant staphylococci, Gould and Cruikshank used a cream containing chlorhexidine (’Hibitane’) (0-5%) with neomycin sulphate (0-5%) or bacitracin (2000 units per g.). This proved to be effective and non-irritant in the dosage recommended.
charged
PROFILE BY PULHESTIB profilesare familiar to most doctors who have served in the Forces. Holt,7 seeking to classify the
PULHEEMS
functional disabilities of handicapped children, suggests a modification of PuLHEBMS called PULHESTIB. Each 5. Hurst, V. J. Hyg., Camb. 1957, 55, 299, 313. 6. Fletcher, R. T. Brit. med. J. 1949, i, 83. 7. Holt, K. S. Arch. Dis. Childh. 1957, 32, 226.
1155 letter stands for a section of the profile : p for general physique. u for upper limbs, L for the lower limbs and locomotion, H for hearing, E for eyes, s for speech, " T tor toilet." I for intelligence, and B for behaviour. Abilities under each section are rated on a four-point scale.1 meaning full ability and 4 meaning no ability. Children with one handicap often have others ; thus a spastic child may also be epileptic and mentally retarded and have a behaviour disorder. Medical and social workers trained to help with one of these handicaps may neglect the others. A classification by lesions or by physical signs is often deceptive. Thus the group " deaf " includes some children whose intellectual defect makes training in a school for the deaf quite impossible. A classification based on the functional abilities of many organs helps to keep the whole child in view. Profiles by PULHESTIB are welcome, but must we have such an ugly name? Dr. Holt should find a more euphonious anagram. PHUTrLEBS trips well but sounds discouraging. But LUPHIBEST is sonorous and indeed might pass as a proper name. CAVAL INFUSION IN THE TREATMENT OF ACUTE RENAL FAILURE
THE
2
principles of conservative treatment of anuria 1 widely agreed in this country. When the illness is mild the patient can be fed orally on lactose and water 3a regimen that can be tolerated for two weeks or even longer. In more severe cases it may be necessary to resort to intragastric tube-feeding 1, though the originators of the method use it much less often now4 and prefer are
caval infusion after catheterisation 5-8. Chambers and Smith9 have lately described their experience of this technique. In one of the Glasgow hospital sectors, which has more than 3000 beds, these workers have since 1950 encountered 29 patients with acute renal failure, of whom 8 needed caval catheterisation. They have also applied this technique to 2 cases in which severe postoperative illness and intestinal obstruction necessitated long-continued intravenous therapy. They use a nylon cardiac catheter (no. 9F) inserted into the right femoral vein via a cut-down on the great saphenous vein at its upper end. The catheter is so placed that its tip lies just below the entry of the inferior vena cava into the right atrium, and the hypertonic infusion is diluted by the largest possible blood-flow. Chambers and Smith emphasise that flow through the catheter must be continuous, and they place a Y-piece in the rubber-tubing so that a second reservoir of fluid is available when the first is being replenished. Heparin (1000 units per 500 ml.) is added to the infusion. Of 10 patients so treated for periods of four to twenty-five days, 6 survived and 4 died. It is thought that the 6 surviving patients owed their lives to caval therapy, and that such therapy did not contribute in any way to the deaths (though necropsy was carried out in only 2 of the 4 fatal cases). Death was delayed for remarkably long periods in inevitably fatal cases. There was no wound sepsis at the site of catheter insertion, no pulmonary embolism, and no trouble in withdrawing the catheter at the cessation of treatment. There was no need of an artificial kidney in this series. Caval catheterisation has not been universally accepted, and Taylor 10, in cases of acute renal failure following 1. Bull, G. M., Joekes, A. M., Lowe, K. G. Lancet, 1949, ii, 229. 2. Evans, B. M., Hughes-Jones, N. C., Milne, M. D., Yellowlees, H. ibid. 1953, ii, 791. 3. Oard, H. C., Walker, G. I. Jr. Amer. J. Med. 1955, 18, 199. 4. Bull, G. M., Joekes, A. M., Lowe, K. G. Lancet, 1955, ii, 1152. 5. De Keyser, R., Van Eeckhoutte, P., Kop, P. S. M., Kolff, W. J. Ned. Tijdschr. Geneesk. 1949, 93, 2386. 6. Russell, C. S., Dewhurst, C. J., Brace, J. C. Lancet, 1954, i, 902. 7. Shaw, G., Mair, J. ibid. p. 1031. 8. Chalmers, J. A., Fawns, H. T. ibid. 1955, i, 79. 9. Chambers, J. W., Smith, G. Brit. J. Surg. 1957, 45, 160. 10. Taylor, W. H. Lancet. Oct. 12, 1957. p. 703.
head injury and surgical operation, has largely abandoned it in favour of infusing 5-20°° glucose solution through a polyethylene catheter inserted several inches into a vein. Publication of further series of cases of acute renal failure treated by caval catheterisation would help to define its real value in this condition.
peripheral
FIVE YEARS OLD
FROM its foundation the College of General Practitioners. which was five vears old on Nov. 19, has set much store by its faculties and peripheral councils ; and with new councils in Australia and New Zealand, and an active faculty in Kenya, its influence is spreading far faculties in all ; twentyafield. There are now two of these are in the United Kingdom and the remainder overseas. The faculties give elasticity to the College, for they enable its activities to be adjusted to local conditions, particularly in undergraduate education, postgraduate education, and research. (In Canada the College of General Practice is firmly established, and shares the same ideals.) But the expansion of the College has not been wholly at the periphery ; increasing demands on the centre have made it necessary to move the College office to more spacious accommodation. The fifth annual report shows that there has been further extension of the work of the three main committees of council. The undergraduate who qualifies without having had personal experience of good general practice will soon be the exception, and educational activities in every faculty ensure that members and associates can honour their obligation to undertake postgraduate study. Here again much of the success achieved has been due to the efficient working of the faculty system. The research committee has had the support of a research register of increasing size and value. College investigations, both large and small, are in progress, some in collaboration with other research bodies. A College records unit is to be established to undertake the continued study of morbidity in general practice. This work, together with the coordination of the research of the councils and faculties, throws a heavy strain on the financial and personal resources of the College, and the limit of voluntary endeavour has almost been reached. In the spiritual sense, the College makes steady progress. It has examined itself and studied its own criteria for entrance and continued membership. No doubt these will become stricter. It remains true to the academic standard which it has set for itself.
thirty-five
STERILISING SYRINGES BY RADIATION THE demand for sterile syringes and needles is becoming so great that more and more hospitals are considering the advisability of starting a central syringe service. How widely the demand for syringes varies between different hospitals has been shown by Murphy,l who chose an area of East Anglia containing hospitals of all types and took a census of injections for a week. At one end of the scale a general (acute) hospital with only 16-1% of the total beds accounted for 56-7% of all injections, while at the other end a mental hospital with 44-9% of the total beds accounted for only 9-0% of the injections. Opinions have differed on the best methods of sterilising syringes and needles ; and some hospitals still use the autoclave for this purpose, despite the Medical Research Council’s insistence2 that hot-air sterilisation is best. Grave theoretical objections to autoclaves for sterilising assembled syringes have been raised by Darmady and Hughes,33 who point out that it is difficult for steam to penetrate between the plunger and barrel of an assembled syringe, 1. Murphy, E. C. Mon. Bull. Min. Hlth Lab. Serv. 1957, 16, 212. 2. The Sterilisation, Use and Care of Syringes. Medical Research Council War Memorandum no. 15. H.M. Stationery Office, 1945. 3. Darmady, E. M., Hughes, K. E. Lancet, 1955, i, 513.