- Email: [email protected]
THE LEAKING UMBRELLA
242
the need to identify these new viruses, and collaboration at an international level will be needed to prevent a great deal of wasteful investigation. Another need is for easier methods of virus investigation which would reduce and simplify necessary comparisons with known viruses. In all these directions the Rockefeller Foundation has given a lead which others should surely follow. THE UNDESCENDED TESTIS
COMMENTING on a leading articleseveral correspondents implied that discussion on the management of the undescended testis is doomed to futility until we know more of its natural history. We are at last distinguishing maldescent from incomplete descent, and most of us are trying to distinguish between the retracted and the incompletely descended organ; but Dr. Winkel Smith2 rightly pointed out that " no material yet exists which can conclusively indicate the right approach to this very important clinical subject ". A survey of schoolboys conducted by the East Anglian Branch of the Society of Medical Officers of Health3 must be acclaimed as a serious effort to collect such material. About forty school medical officers carried out the investigation in the areas of six local authorities between September, 1956, and July, 1957. The facts were collected at the routine medical inspection of schoolchildren aged 5, 11, 14, and in some areas 8 years. School-leavers are also examined; and the ages of these ranged from 14 to 17. Of 23,398 boys scheduled for inspection 22,218 were examined for unilateral or bilateral empty scrotum. In his pertinent criticism of earlier figures, Mr. Scorer4 suggested that it was wrong to imply that " there is a natural process of descent over a period of many years "; and that our rough estimate of the prevalence of nondescent (in 10% at birth, in 2% at puberty, and in 0-2% of men) rested on questionable evidence. Instead of relying on earlier statistics, collected without preliminary definition of the retractile testis, he had himself examined 1500 full-term infants (weighing 5 lb. 9 oz. or more) at birth and had found one or both testes undescended in 51 (3-4%). By the end of the first month of life the testes had descended in about half of these; and by the end of the first year the prevalence of non-descent in the first 1000 was 0-7% 5. His findings led him to conclude (and his conclusions are shared by many) that " spontaneous descent takes place early in life but very seldom later ", and that " the incidence of undescended testis remains almost constant from infancy onwards " 4. In the East Anglian survey, on the other hand, unilateral undescended testis was found in 4-3% of 5-year-old boys, in 4-5% of 8-year-olds, in 3-5% of 11-year-olds, and in only 0-6% of school-leavers. The prevalence of bilateral empty scrotum was 2-0% at 5 years, 2-3% at 8 years, 1-8% at 11 years, and 0-1% at school-leaving age. The East Anglian workers themselves have subjected these figures to searching criticism, which illustrates the many pitfalls of collective surveys. In one of the six local-authority areas the school health service is divided, for administrative purposes, into nine districts ; and since ’,’ there is no great overlap between the duties of school doctors in adjoining [districts], it was thought that variations in the results for the different [districts] might give’ These an estimate of the effect of different observers ". 1. Lancet, 1957, ii, 989. 2. Winkel Smith, C. C. ibid. 1957, ii, 1172. 3. Report of the East Anglian Branch, Society of Medical Officers of Health. Med. Offr, 1958, 100, 379. 4. Scorer, C. G. Lancet, 1957, ii, 1124. 5. Scorer, C. G. Arch. Dis. Childh. 1956, 31, 198.
differences proved considerable. The prevalence of unilateral empty scrotum at 5 years varied from 0-71 % recorded in one district by one observer to 14-65% recorded in another district by another observer; and the corresponding ranges in 8-yearolds and 11-year-olds were 1-06-10-41% and 2-30-5-59%. The pooled results showed less variation; but this was still wide. (Unilateral empty scrotum was found in 1-8% of 1600 5-year-old boys in one area and in 5% of 2000 boys in another.) Nor is the suggestion that " the lowest estimates are likely to be the most accurate " entirely acceptable. It is true that by far the most important source of error is retraction; but it is not impossible to " miss " an empty scrotum-mistaking a hernial sac with omentum, fluid, or bowel for a testis.
It might be supposed that, even if the figures are too high, the trend between the age of 5 years and schoolleaving strongly suggests that a considerable proportion of undescended organs descend just before or during puberty. But this would not be a fair conclusion, since at puberty many retractile testes lose their retractility. Retraction remains, in fact, the bugbear of all statistical work on this important subject; and this is the more depressing since we are still almost totally ignorant of
its
causes
and mechanism. THE LEAKING UMBRELLA
IT might be regarded as misfortune that SanchezUbeda and his colleagues1 undertook to investigate the value of what is vulgarly known as the antibiotic umbrella, just as the staphylococcus was raising its ugly head; but there is a moral to the story. They originally intended to observe a considerable series of postoperative cases, since " clean cases were expected to yield a low prevalence of infection-thus requiring a large series to reveal statistical significance. In fact their study ceased after 511 consecutive cases had been seen, because the staphylococcus had mocked them. Alternate cases (255 in all) were given antibiotic cover and were compared with the control group of 256 in which no antibiotic was given. In 152 cases the procedures (such as alimentary resection) might be expected to give rise to contamination; only 359 were frankly clean cases. In these the complication-rate in terms of both wound and respiratory infection was quite unaffected by the administration of antibiotics, the woundinfection rate being 5% in both treated and control groups; but allergic manifestations put the antibiotic group at a disadvantage, raising the overall complication-rate to 9-5% compared with 5-6%. In the 152 dirty" cases the incidence of wound infection was identical in the two groups, being just over 14% ; the total complication-rate was also equal at 22-23%. These results reflect those of McKittrick and Wheelock in a pilot study undertaken in the era before the resistant staphylococcus.2 "
"
"
"
In the investigation by Sandrez-Ubeda et al. the antibiotics administered were penicillin and streptomycin, which would have no effect on resistant staphylococci. The moral is that prophylactic blunderbuss therapy with no specific organism in mind is like shadow-boxing with an elusive unidentified opponent; and it is as pointless as the blind administration of antibiotics when vague and uncertain disorder is present. Dietrick et al. point out how abdominal symptoms may thus become masked so that conditions such as acute appendicitis remain undiagnosed and yet unrelieved, leading at best to lengthy illness, at worst to
catastrophe.
Sanchez-Ubeda, R., Fernand, E., Rousselot, L. M. New Engl. J. Med. 1958, 259, 1045. 2. McKittrick, L. S., Wheelock, F. C. Surg. Gynec. Obstet. 1954, 99, 376. 3. Dietrick, R. B., Byrd, C. W., Lawson, J. A. Ann. Surg. 1958, 148, 985. 1.
the need to identify these new viruses, and collaboration at an international level will be needed to prevent a great deal of wasteful investigation. Another need is for easier methods of virus investigation which would reduce and simplify necessary comparisons with known viruses. In all these directions the Rockefeller Foundation has given a lead which others should surely follow. THE UNDESCENDED TESTIS
COMMENTING on a leading articleseveral correspondents implied that discussion on the management of the undescended testis is doomed to futility until we know more of its natural history. We are at last distinguishing maldescent from incomplete descent, and most of us are trying to distinguish between the retracted and the incompletely descended organ; but Dr. Winkel Smith2 rightly pointed out that " no material yet exists which can conclusively indicate the right approach to this very important clinical subject ". A survey of schoolboys conducted by the East Anglian Branch of the Society of Medical Officers of Health3 must be acclaimed as a serious effort to collect such material. About forty school medical officers carried out the investigation in the areas of six local authorities between September, 1956, and July, 1957. The facts were collected at the routine medical inspection of schoolchildren aged 5, 11, 14, and in some areas 8 years. School-leavers are also examined; and the ages of these ranged from 14 to 17. Of 23,398 boys scheduled for inspection 22,218 were examined for unilateral or bilateral empty scrotum. In his pertinent criticism of earlier figures, Mr. Scorer4 suggested that it was wrong to imply that " there is a natural process of descent over a period of many years "; and that our rough estimate of the prevalence of nondescent (in 10% at birth, in 2% at puberty, and in 0-2% of men) rested on questionable evidence. Instead of relying on earlier statistics, collected without preliminary definition of the retractile testis, he had himself examined 1500 full-term infants (weighing 5 lb. 9 oz. or more) at birth and had found one or both testes undescended in 51 (3-4%). By the end of the first month of life the testes had descended in about half of these; and by the end of the first year the prevalence of non-descent in the first 1000 was 0-7% 5. His findings led him to conclude (and his conclusions are shared by many) that " spontaneous descent takes place early in life but very seldom later ", and that " the incidence of undescended testis remains almost constant from infancy onwards " 4. In the East Anglian survey, on the other hand, unilateral undescended testis was found in 4-3% of 5-year-old boys, in 4-5% of 8-year-olds, in 3-5% of 11-year-olds, and in only 0-6% of school-leavers. The prevalence of bilateral empty scrotum was 2-0% at 5 years, 2-3% at 8 years, 1-8% at 11 years, and 0-1% at school-leaving age. The East Anglian workers themselves have subjected these figures to searching criticism, which illustrates the many pitfalls of collective surveys. In one of the six local-authority areas the school health service is divided, for administrative purposes, into nine districts ; and since ’,’ there is no great overlap between the duties of school doctors in adjoining [districts], it was thought that variations in the results for the different [districts] might give’ These an estimate of the effect of different observers ". 1. Lancet, 1957, ii, 989. 2. Winkel Smith, C. C. ibid. 1957, ii, 1172. 3. Report of the East Anglian Branch, Society of Medical Officers of Health. Med. Offr, 1958, 100, 379. 4. Scorer, C. G. Lancet, 1957, ii, 1124. 5. Scorer, C. G. Arch. Dis. Childh. 1956, 31, 198.
differences proved considerable. The prevalence of unilateral empty scrotum at 5 years varied from 0-71 % recorded in one district by one observer to 14-65% recorded in another district by another observer; and the corresponding ranges in 8-yearolds and 11-year-olds were 1-06-10-41% and 2-30-5-59%. The pooled results showed less variation; but this was still wide. (Unilateral empty scrotum was found in 1-8% of 1600 5-year-old boys in one area and in 5% of 2000 boys in another.) Nor is the suggestion that " the lowest estimates are likely to be the most accurate " entirely acceptable. It is true that by far the most important source of error is retraction; but it is not impossible to " miss " an empty scrotum-mistaking a hernial sac with omentum, fluid, or bowel for a testis.
It might be supposed that, even if the figures are too high, the trend between the age of 5 years and schoolleaving strongly suggests that a considerable proportion of undescended organs descend just before or during puberty. But this would not be a fair conclusion, since at puberty many retractile testes lose their retractility. Retraction remains, in fact, the bugbear of all statistical work on this important subject; and this is the more depressing since we are still almost totally ignorant of
its
causes
and mechanism. THE LEAKING UMBRELLA
IT might be regarded as misfortune that SanchezUbeda and his colleagues1 undertook to investigate the value of what is vulgarly known as the antibiotic umbrella, just as the staphylococcus was raising its ugly head; but there is a moral to the story. They originally intended to observe a considerable series of postoperative cases, since " clean cases were expected to yield a low prevalence of infection-thus requiring a large series to reveal statistical significance. In fact their study ceased after 511 consecutive cases had been seen, because the staphylococcus had mocked them. Alternate cases (255 in all) were given antibiotic cover and were compared with the control group of 256 in which no antibiotic was given. In 152 cases the procedures (such as alimentary resection) might be expected to give rise to contamination; only 359 were frankly clean cases. In these the complication-rate in terms of both wound and respiratory infection was quite unaffected by the administration of antibiotics, the woundinfection rate being 5% in both treated and control groups; but allergic manifestations put the antibiotic group at a disadvantage, raising the overall complication-rate to 9-5% compared with 5-6%. In the 152 dirty" cases the incidence of wound infection was identical in the two groups, being just over 14% ; the total complication-rate was also equal at 22-23%. These results reflect those of McKittrick and Wheelock in a pilot study undertaken in the era before the resistant staphylococcus.2 "
"
"
"
In the investigation by Sandrez-Ubeda et al. the antibiotics administered were penicillin and streptomycin, which would have no effect on resistant staphylococci. The moral is that prophylactic blunderbuss therapy with no specific organism in mind is like shadow-boxing with an elusive unidentified opponent; and it is as pointless as the blind administration of antibiotics when vague and uncertain disorder is present. Dietrick et al. point out how abdominal symptoms may thus become masked so that conditions such as acute appendicitis remain undiagnosed and yet unrelieved, leading at best to lengthy illness, at worst to
catastrophe.
Sanchez-Ubeda, R., Fernand, E., Rousselot, L. M. New Engl. J. Med. 1958, 259, 1045. 2. McKittrick, L. S., Wheelock, F. C. Surg. Gynec. Obstet. 1954, 99, 376. 3. Dietrick, R. B., Byrd, C. W., Lawson, J. A. Ann. Surg. 1958, 148, 985. 1.