855

conclusions can only be tentative. The discussion

provided a reminder that a disease may respond differentlyto the same control measures on different occasions.The success and failure which, some years ago, attendedtwo similar trials of dust-suppressive measures for thecontrol of cross-infection in measles wards may havebeen due to differences in the intensity of the prevailingbacterial load. The authors of the report emphasisedthat present knowledge of the modes of transmission ofinfectious disease in the classroom does not warrant thedefinite formulation of new control measures ; and theyre-stated their view that the general use of ultravioletirradiation is not justifiable, since the infections forwhich it seemed effective accounted for a relativelyinsignificant proportion of the total absences.This notable piece of team-work makes it clear that

much has yet to be learnt about the transmission ofrespiratory disease, but it encourages the belief that

inquiries of this kind fully repay the great labourinvolved.

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.

ORIGIN OF IDIOPATHIC EPILEPSY

AT necropsy in cases of epilepsy sclerosis of Ammon’shorn, on the medial surface of the temporal lobe, isoften the only abnormality (apart from cerebral con-

gestion and cedema when death has taken place during afit). In "idiopathic" epilepsy, moreover, the clinical

picture often suggests abnormal discharge from thetemporal lobe. These observations may be connected,for histological studies by Earle et al.l suggest thattemporal-lobe epilepsy commonly results from cerebralanoxia or injury at birth. Lilienfeld and Pasamanick,2 inan inquiry into the birth-histories of 396 epileptic children,found appreciably more complications of pregnancyand parturition, and a higher incidence of prematurityand neonatal abnormality, in the epileptics than in acontrol group. These workers, who previously made asimilar study of pregnancy complications in the aetiologyof cerebral palsy,3 suggest that epilepsy should take itsplace in a " continuum of reproductive casualty," rangingfrom stillbirths and neonatal deaths to cerebral palsies.Birth injury, though probably not the one cause of

idiopathic epilepsy, should be recognised as a possibleprecipitating factor.

VIRULENCE-ENHANCING EFFECT OF ANTIBIOTICSIT is well known that administration of antibiotics,

especially those with a broad spectrum, may sometimesupset the balance of host-parasite relations so that

organisms normally leading a commensal existence onmucous membranes become virulent and set up infection.*The underlying mechanism of this important change isnot easy to examine in man, and our ideas about it arebased more on our estimate of what seems probable thanon observed facts. For example, it is commonly assumedthat staphylococci which cause enterocolitis duringantibiotic therapy do so because, being or becomingresistant to the antibiotic, they colonise the intestinalmucosa when the antibiotic has removed from the

competition for available nutrients the antibiotic-sensitive organisms which normally inhabit the intestine.Certainly staphylococci are often isolated in pure culturefrom this type of enterocolitis, but is it true that sup-pression of all organisms save one species encourages thatone to increase in virulence ? ’1 Bonhoff et al. havedescribed a simple but ingenious experiment which willallow this and similar problems to be examined in themouse. With streptomycin as antibiotic and strepto-mycin-resistant Salmonella enteritidis as test pathogen,

they found that one dose of 50 mg. of streptomycin bymouth 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-tubetwenty-four hours after the dose of streptomycin. Thiseffect of the single dose of 50 mg. of streptomycin couldbe detected, although it diminished, for about five days ;doses of 5-10 mg. of streptomycin caused smallerincreases in susceptibility, but a single dose of 1 mg. hadno effect. Mice uninfected with salmonella received 500mg. 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-enhancingactivity of the streptomycin on the salmonella infectionwas due to changes in the associated microflora of theintestine. They advance arguments against otherpossible modes of action of the streptomycin-forexample, on the tissues of the mouse, or by stimulatinggrowth of salmonella-but the merit of their presentcontribution lies less in the arguments and conclusionsthan in the convenience of their experimental model.Bonhoff et al. now propose to examine the nature of thechanges in the microflora of the intestine. It will be

interesting to learn what these are, and whether they areindeed the cause of the enhanced infection.

SURGICAL WAITING-LISTS

HOSPITAL waiting-lists have long vexed both patientsand staff. Where it is possible to apply the method nowbeing tested in Birmingham, surgical waiting-lists-which are the longest-can be reduced to manageablelength.Most cases on general surgical waiting-lists are herniae,

hoemorrhoids, or varicose veins. If the average stay inhospital of a patient with hernia is ten days (in thepractice of many surgeons it is longer) then one hospitalbed can accommodate only 36 patients in a year. Butfor most such cases the elaborate organisation of asurgical ward is unnecessary after the third post-operative day, when the patient could go to a conva-lescent institution. In this way two patients could beadmitted and operated on every week for each hospitalbed set aside for the purpose, provided that the bed waspermanently covered by two convalescent beds. Ifevery surgeon set aside one bed for herniae, one herniaoperation would be added to each operating-list (suppos-ing that the surgeon operates twice weekly). Thus theturnover of one bed would be increased almost threefoldto a hundred a year. The distribution of beds betweenthe surgeons is probably better than setting aside ablock of beds as a hernia unit, to be " worked " by oneor two surgeons (perhaps registrars), whose lists wouldconsist of little else. Waiting-lists for surgical treatmentof varicose veins are more easily dealt with, since patientscan return home the day after operation ; here the

limiting factor is the number of operating sessions.Most convalescent institutions have a trained nurse andare visited by a doctor ; so it should be possible totransfer from hospital after ten days’ stay patientswho have had operations for hsemorrhoids; they wouldstay in the convalescent home for a further ten days.

In the pilot scheme at Birmingham, the surgeonreserves one bed for patients with herniae ; and if a

complication prolongs the patient’s stay he is transferredto another bed. The scheme was started in the middleof May this year, when about 60 cases of hernia wereon one waiting-list, and both the numbers and the waiting-time were increasing. In the nineteen weeks from Jan. 1to May 17 only 10 herniae had been treated ; but in the

eighteen subsequent weeks 32 were treated, and thewaiting-list had fallen to 25 and the waiting-time toeight months. The date by which all the herniae willhave been treated can now be predicted. By this planpatients can be warned many weeks in advance of thedate of their admission.