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SURGICAL WAITING-LISTS
855 The discussion conclusions can only be tentative. provided a reminder that a disease may respond differently
control measures on different occasions. and failure which, some years ago, attended two similar trials of dust-suppressive measures for the control of cross-infection in measles wards may have been due to differences in the intensity of the prevailing bacterial load. The authors of the report emphasised that present knowledge of the modes of transmission of infectious disease in the classroom does not warrant the definite formulation of new control measures ; and they re-stated their view that the general use of ultraviolet irradiation is not justifiable, since the infections for which it seemed effective accounted for a relatively insignificant proportion of the total absences. This notable piece of team-work makes it clear that much has yet to be learnt about the transmission of respiratory disease, but it encourages the belief that inquiries of this kind fully repay the great labour involved. ORIGIN OF IDIOPATHIC EPILEPSY AT necropsy in cases of epilepsy sclerosis of Ammon’s horn, on the medial surface of the temporal lobe, is often the only abnormality (apart from cerebral congestion and cedema when death has taken place during a fit). In "idiopathic" epilepsy, moreover, the clinical picture often suggests abnormal discharge from the temporal lobe. These observations may be connected, for histological studies by Earle et al.l suggest that temporal-lobe epilepsy commonly results from cerebral anoxia or injury at birth. Lilienfeld and Pasamanick,2 in an inquiry into the birth-histories of 396 epileptic children, found appreciably more complications of pregnancy and parturition, and a higher incidence of prematurity and neonatal abnormality, in the epileptics than in a control group. These workers, who previously made a similar study of pregnancy complications in the aetiology of cerebral palsy,3 suggest that epilepsy should take its place in a " continuum of reproductive casualty," ranging from stillbirths and neonatal deaths to cerebral palsies. Birth injury, though probably not the one cause of idiopathic epilepsy, should be recognised as a possible precipitating factor. to the
The
same
success
VIRULENCE-ENHANCING EFFECT OF ANTIBIOTICS IT is well known that administration of antibiotics, especially those with a broad spectrum, may sometimes upset the balance of host-parasite relations so that organisms normally leading a commensal existence on mucous membranes become virulent and set up infection.* The underlying mechanism of this important change is not easy to examine in man, and our ideas about it are based more on our estimate of what seems probable than For example, it is commonly assumed on observed facts. that staphylococci which cause enterocolitis during antibiotic therapydo so because, being or becoming resistant to the antibiotic, they colonise the intestinal mucosa when the antibiotic has removed from the competition for available nutrients the antibioticsensitive organisms which normally inhabit the intestine. Certainly staphylococci are often isolated in pure culture from this type of enterocolitis, but is it true that suppression of all organisms save one species encourages that one to increase in virulence ? ’1 Bonhoff et al. have described a simple but ingenious experiment which will allow this and similar problems to be examined in the mouse. With streptomycin as antibiotic and streptomycin-resistant Salmonella enteritidis as test pathogen, 1. Earle, K. M., Baldwin, M., Penfield, W. Arch. Neurol. Psychiat., Chicago, 1953, 69, 27. 2. Lilienfeld, A. M., Pasamanick, B. J. Amer. med. Ass. 1954,
155, 719.
3. Lilienfeld, A. M., Parkhurst, E. Amer. J. Hyg. 1951, 53, 262. 4. Hay, P., MoKenzie, P. Lancet, 1954, i, 945. 5. See Ibid, p. 967. 6. Bonhoff, M., Drake, B. L., Miller, C. P. Proc. Soc. exp. Biol., N.Y. 1954, 86, 132.
found that one dose of 50 mg. of streptomycin by mouth reduced the infecting dose for half the mice (LD’50) from 100,000 to less than 3 salmonellae, the organisms being inoculated directly by stomach-tube twenty-four hours after the dose of streptomycin. This effect of the single dose of 50 mg. of streptomycin could be detected, although it diminished, for about five days ; doses of 5-10 mg. of streptomycin caused smaller increases in susceptibility, but a single dose of 1 mg. had no effect. Mice uninfected with salmonella received 500 mg. of streptomycin by mouth without apparent harm. There is still no conclusive evidence for or against the belief of Bonhoff et al. that the virulence-enhancing activity of the streptomycin on the salmonella infection was due to changes in the associated microflora of the intestine. They advance arguments against other possible modes of action of the streptomycin-for example, on the tissues of the mouse, or by stimulating growth of salmonella-but the merit of their present contribution lies less in the arguments and conclusions than in the convenience of their experimental model. Bonhoff et al. now propose to examine the nature of the changes in the microflora of the intestine. It will be interesting to learn what these are, and whether they are indeed the cause of the enhanced infection. SURGICAL WAITING-LISTS HOSPITAL waiting-lists have long vexed both patients and staff. Where it is possible to apply the method now being tested in Birmingham, surgical waiting-listswhich are the longest-can be reduced to manageable
they
length. Most
cases on
general surgical waiting-lists
are
herniae,
varicose veins. If the average stay in hospital of a patient with hernia is ten days (in the practice of many surgeons it is longer) then one hospital bed can accommodate only 36 patients in a year. But for most such cases the elaborate organisation of a surgical ward is unnecessary after the third postoperative day, when the patient could go to a convalescent institution. In this way two patients could be admitted and operated on every week for each hospital bed set aside for the purpose, provided that the bed was permanently covered by two convalescent beds. If every surgeon set aside one bed for herniae, one hernia operation would be added to each operating-list (supposing that the surgeon operates twice weekly). Thus the turnover of one bed would be increased almost threefold to a hundred a year. The distribution of beds between the surgeons is probably better than setting aside a block of beds as a hernia unit, to be " worked " by one or two surgeons (perhaps registrars), whose lists would consist of little else. Waiting-lists for surgical treatment of varicose veins are more easily dealt with, since patients here the can return home the day after operation ; limiting factor is the number of operating sessions. Most convalescent institutions have a trained nurse and so it should be possible to are visited by a doctor ; transfer from hospital after ten days’ stay patients who have had operations for hsemorrhoids; they would stay in the convalescent home for a further ten days. In the pilot scheme at Birmingham, the surgeon reserves one bed for patients with herniae ; and if a complication prolongs the patient’s stay he is transferred to another bed. The scheme was started in the middle of May this year, when about 60 cases of hernia were on one waiting-list, and both the numbers and the waitingtime were increasing. In the nineteen weeks from Jan. 1 to May 17 only 10 herniae had been treated ; but in the eighteen subsequent weeks 32 were treated, and the waiting-list had fallen to 25 and the waiting-time to eight months. The date by which all the herniae will have been treated can now be predicted. By this plan patients can be warned many weeks in advance of the date of their admission.
hoemorrhoids,
or
control measures on different occasions. and failure which, some years ago, attended two similar trials of dust-suppressive measures for the control of cross-infection in measles wards may have been due to differences in the intensity of the prevailing bacterial load. The authors of the report emphasised that present knowledge of the modes of transmission of infectious disease in the classroom does not warrant the definite formulation of new control measures ; and they re-stated their view that the general use of ultraviolet irradiation is not justifiable, since the infections for which it seemed effective accounted for a relatively insignificant proportion of the total absences. This notable piece of team-work makes it clear that much has yet to be learnt about the transmission of respiratory disease, but it encourages the belief that inquiries of this kind fully repay the great labour involved. ORIGIN OF IDIOPATHIC EPILEPSY AT necropsy in cases of epilepsy sclerosis of Ammon’s horn, on the medial surface of the temporal lobe, is often the only abnormality (apart from cerebral congestion and cedema when death has taken place during a fit). In "idiopathic" epilepsy, moreover, the clinical picture often suggests abnormal discharge from the temporal lobe. These observations may be connected, for histological studies by Earle et al.l suggest that temporal-lobe epilepsy commonly results from cerebral anoxia or injury at birth. Lilienfeld and Pasamanick,2 in an inquiry into the birth-histories of 396 epileptic children, found appreciably more complications of pregnancy and parturition, and a higher incidence of prematurity and neonatal abnormality, in the epileptics than in a control group. These workers, who previously made a similar study of pregnancy complications in the aetiology of cerebral palsy,3 suggest that epilepsy should take its place in a " continuum of reproductive casualty," ranging from stillbirths and neonatal deaths to cerebral palsies. Birth injury, though probably not the one cause of idiopathic epilepsy, should be recognised as a possible precipitating factor. to the
The
same
success
VIRULENCE-ENHANCING EFFECT OF ANTIBIOTICS IT is well known that administration of antibiotics, especially those with a broad spectrum, may sometimes upset the balance of host-parasite relations so that organisms normally leading a commensal existence on mucous membranes become virulent and set up infection.* The underlying mechanism of this important change is not easy to examine in man, and our ideas about it are based more on our estimate of what seems probable than For example, it is commonly assumed on observed facts. that staphylococci which cause enterocolitis during antibiotic therapydo so because, being or becoming resistant to the antibiotic, they colonise the intestinal mucosa when the antibiotic has removed from the competition for available nutrients the antibioticsensitive organisms which normally inhabit the intestine. Certainly staphylococci are often isolated in pure culture from this type of enterocolitis, but is it true that suppression of all organisms save one species encourages that one to increase in virulence ? ’1 Bonhoff et al. have described a simple but ingenious experiment which will allow this and similar problems to be examined in the mouse. With streptomycin as antibiotic and streptomycin-resistant Salmonella enteritidis as test pathogen, 1. Earle, K. M., Baldwin, M., Penfield, W. Arch. Neurol. Psychiat., Chicago, 1953, 69, 27. 2. Lilienfeld, A. M., Pasamanick, B. J. Amer. med. Ass. 1954,
155, 719.
3. Lilienfeld, A. M., Parkhurst, E. Amer. J. Hyg. 1951, 53, 262. 4. Hay, P., MoKenzie, P. Lancet, 1954, i, 945. 5. See Ibid, p. 967. 6. Bonhoff, M., Drake, B. L., Miller, C. P. Proc. Soc. exp. Biol., N.Y. 1954, 86, 132.
found that one dose of 50 mg. of streptomycin by mouth reduced the infecting dose for half the mice (LD’50) from 100,000 to less than 3 salmonellae, the organisms being inoculated directly by stomach-tube twenty-four hours after the dose of streptomycin. This effect of the single dose of 50 mg. of streptomycin could be detected, although it diminished, for about five days ; doses of 5-10 mg. of streptomycin caused smaller increases in susceptibility, but a single dose of 1 mg. had no effect. Mice uninfected with salmonella received 500 mg. of streptomycin by mouth without apparent harm. There is still no conclusive evidence for or against the belief of Bonhoff et al. that the virulence-enhancing activity of the streptomycin on the salmonella infection was due to changes in the associated microflora of the intestine. They advance arguments against other possible modes of action of the streptomycin-for example, on the tissues of the mouse, or by stimulating growth of salmonella-but the merit of their present contribution lies less in the arguments and conclusions than in the convenience of their experimental model. Bonhoff et al. now propose to examine the nature of the changes in the microflora of the intestine. It will be interesting to learn what these are, and whether they are indeed the cause of the enhanced infection. SURGICAL WAITING-LISTS HOSPITAL waiting-lists have long vexed both patients and staff. Where it is possible to apply the method now being tested in Birmingham, surgical waiting-listswhich are the longest-can be reduced to manageable
they
length. Most
cases on
general surgical waiting-lists
are
herniae,
varicose veins. If the average stay in hospital of a patient with hernia is ten days (in the practice of many surgeons it is longer) then one hospital bed can accommodate only 36 patients in a year. But for most such cases the elaborate organisation of a surgical ward is unnecessary after the third postoperative day, when the patient could go to a convalescent institution. In this way two patients could be admitted and operated on every week for each hospital bed set aside for the purpose, provided that the bed was permanently covered by two convalescent beds. If every surgeon set aside one bed for herniae, one hernia operation would be added to each operating-list (supposing that the surgeon operates twice weekly). Thus the turnover of one bed would be increased almost threefold to a hundred a year. The distribution of beds between the surgeons is probably better than setting aside a block of beds as a hernia unit, to be " worked " by one or two surgeons (perhaps registrars), whose lists would consist of little else. Waiting-lists for surgical treatment of varicose veins are more easily dealt with, since patients here the can return home the day after operation ; limiting factor is the number of operating sessions. Most convalescent institutions have a trained nurse and so it should be possible to are visited by a doctor ; transfer from hospital after ten days’ stay patients who have had operations for hsemorrhoids; they would stay in the convalescent home for a further ten days. In the pilot scheme at Birmingham, the surgeon reserves one bed for patients with herniae ; and if a complication prolongs the patient’s stay he is transferred to another bed. The scheme was started in the middle of May this year, when about 60 cases of hernia were on one waiting-list, and both the numbers and the waitingtime were increasing. In the nineteen weeks from Jan. 1 to May 17 only 10 herniae had been treated ; but in the eighteen subsequent weeks 32 were treated, and the waiting-list had fallen to 25 and the waiting-time to eight months. The date by which all the herniae will have been treated can now be predicted. By this plan patients can be warned many weeks in advance of the date of their admission.
hoemorrhoids,
or