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of information seems to open the way to an attackon resistance by blocking detoxication with appro-priate synergists. But, while this can be done withlaboratory strains, it seldom works in the field,because, it is now realised, several different typesof defence mechanisms can be developed by resistantstrains and it is extremely hard to overcome themall simultaneously.

In practice at the moment, therefore, the simplestway of coping with resistance is still the best-that

is, to use as little pesticide as is consistent with

adequate control and, if resistance should develop,to be ready with an alternative. The wide basic

knowledge gained by the research on resistancecan be very valuable in the selection of the best

alternatives, as was illustrated at an internationalconference in Atlanta last February.I3

NITROFURANTOIN

ALTHOUGH many drugs are known to combat theorganisms commonly responsible for urinary-tractinfection, this condition continues to present difficul-ties in management. Its high incidence in women,and the frequency with which attacks follow sexualintercourse, suggest that the urethral trauma associatedwith intercourse encourages the passage of bacteriainto the bladder, where they multiply during thenight. If so, then the regular administration everynight of an antibacterial agent would be expected toreduce the incidence of such infections. Little 14 foundthat nitrofurantoin 100 mg. nightly eliminated bac-teriuria in 82% of patients, and Professor de Wardenerand his colleagues (p. 1112) now report success witha dose of 50 mg. every night.Nitrofurantoin has been used in the treatment of

urinary-tract infections for more than twenty years,since it is active against many organisms commonlyresponsible for such infection, particularly Escherichiacoli.11 In recent years, however, its popularity haswaned, probably because of the introduction of othereffective chemotherapeutic agents, and also because ofthe incidence of gastrointestinal side-effects." Theseside-effects are closely dose-dependent, however, and,while it is always desirable to relate the dose of a drugto the body-weight of the patient, this is particularlytrue of nitrofurantoin. For this reason the BritishPharmaceutical Codex 1968 recommends a daily doseof 5-8 mg. per kg. body-weight, and it is probablethat such a regimen would reduce the incidence andseverity of these particular side-effects. Even thesedoses may produce high blood-levels in patients withrenal impairment, however, and other more serioustoxic effects may then be seen-such as polyneuritis,the most important adverse effect of treatment withnitrofuran derivatives,16 The findings of Felts et al.17

13. Bull. Wld Hlth Org. 1971, 44, 1.14. Little, P. J. Lancet, 1966, ii, 925.15. Garrod, L. P., O’Grady, F. Antibiotic and Chemotherapy. Edin-

burgh, 1971.16. Meyler, L., Herxheimer, A. Side Effects of Drugs; vol. VI. Excerpta

Medica Foundation, Amsterdam, 1968.17. Felts, J. H., Hayes D. M., Gergen, J. A., Toole, J. F. Am. J. Med.

1971, 51, 295.

suggest that, when renal function is seriously damaged,nitrofurantoin can be given in reduced doses withoutaffecting peripheral-nerve function, but effective anti-microbial levels could be maintained in the urine onlywith a high risk of neurological side-effects. In thesmall nightly dose of 50 mg. suggested by Professorde Wardener and his colleagues, however, and in theabsence of evidence of renal impairment, it is unlikelythat troublesome side-effects will arise.

Conklin and Wagner 18 have lately investigated thebiliary excretion of nitrofurantoin in the dog. Asubstantial amount of the drug was excreted in thebile, and the bile-to-blood ratio was about 200. Sucha ratio indicates that some active secretory process is

required for its transport from blood to bile ratherthan simple diffusion. They also noted a big increasein the rate of flow of bile, which was proportional tothe amount of drug given. Only a few drugs areknown to be authentic hydrocholeretics, and if theseobservations are confirmed in man they may indicateanother field where nitrofurantoin could have thera-peutic possibilities.

THE YOUNG OFFENDER

OFFENDERS in the 17-21 age-group have increasinglyformed a larger share of the total number of convic-tions in Britain, but a Bow Group memorandum 19

argues that they are dealt with in a manner that is hardto justify on any rational basis. The Children and

Young Persons’ Act, 1969 will, when fully implemen-ted, completely reform the prosecution, sentencing,and punishment of those under 17, but the offenderaged 17-21 is tried in the same courts and by thesame people and processes as the adult offender; onlythe sentences differ. The author of the memorandum,Mr. Edward Wilde, advocates the setting up of courtsfor the younger offender separate both from the

juvenile and the magistrates’ courts, which, like juvenilecourts, would have simplified procedures, and whichmight also have a special panel of magistrates withexperience in dealing with this age-group.At present the offender aged 17-21 may be sentenced

to probation, detention centre, borstal, or prison;prison sentences for this age-group may only be forperiods of up to 6 months or over 3 years. Mr. Wildecontends that there is a great deal wrong with the

present sentencing system. There is, he says, a

growing number of intransigent cases among thosecommitted for custodial treatment, particularly amongborstal trainees. Since 1961, as a result of the CriminalJustice Act, courts have been restricted in their powerto send young offenders to prison, and borstal hasremained as the only intermediate-length custodialsentence available. In consequence, the rehabilitativevalue of borstal training has been considerably under-mined. That the borstals are losing much of theireffectiveness is shown by the fact that, whereas beforethe 1939-45 war the rate for reconviction within 3 yearswas 45%, it is now 70%. This may also be a result

18. Conklin, J. D., Wagner, D. L. Br. J. Pharmac. 1971, 43, 140.19. The Forgotten Years. Dealing with the Young Cffender. By

EDWARD WILDE. The Bow Group, 240 High Holborn, LondonW.C.1. 30p (postage 5p).

1130

of the fact that the borstal centres, which are mostlysituated in the country, are unable to provide suitablevocational or leisure training for boys from a rapidlychanging urban environment.Mr. Wilde suggests that before any custodial

sentence is passed on a young offender, a social

inquiry report (prepared by the probation and after-care service), a prison department report (including amedical report), and an antecedents report (preparedby the police) should be considered by the court, andthat copies of these reports should be given to thedefendant or his legal representatives. At present thereis no statutory obligation on a court to obtain a socialinquiry report before sentencing in any case. Courtsshould recognise that " an average standard of health "is necessary in boys sent for training; in the past boyswith club-feet, diabetes, epilepsy, and tuberculosishave been sent to centres. The prison department’sreport should also contain an assessment of the youngoffender’s suitability for institutional treatment. Mr.Wilde believes that prison sentences of under 6 monthsare of no value for the young offender, since thesesentences are served in local prisons along with adultoffenders, where no rehabilitation or training isavailable. Such sentences would be better served indetention centres, and more of these centres should be

opened, so that they could take all young offenderssentenced to short-term imprisonment. With regardto longer terms of imprisonment (of 3 or more years),Mr. Wilde says that it is acknowledged " that a

deterrent sentence as part of a tariff system of justicehas a place in dealing with serious and vicious crime ".

Detention centres serve to provide " a short sharpshock ", with periods of sentence ranging from 2 to 9months. Mr. Wilde believes that courts should beable to impose a detention-centre sentence of 1 month,in order not to disrupt an offender’s family life andemployment prospects, and to avoid some of theeffects of institutionalism. Another suggested reformis that detention-centre and borstal-training systemsshould be merged, so introducing a considerableamount of flexibility into the length and nature oftreatment given to an offender. To be effective, sucha system would require a proper classifying procedureto ensure that the needs and capabilities of each youngoffender were adequately assessed. Special therapeuticunits could be set up for those who are mentally orphysically unsuited to the normal forms of training.Mr. Wilde believes that the distinction between

custodial and non-custodial sentences is at presenttoo rigid. He would like to see a system of weekenddetention introduced, similar to systems operating inNew Zealand and Belgium, and the attendance-centresystem, under which offenders are required to reportto the centre-usually for 3 hours on a Saturdayafternoon-expanded. There are at present only 2such centres, one in London and one in Manchester,and rural as well as urban centres should be set up.More probation homes are also needed, and greateremphasis should be placed by the courts on theaftercare requirements for offenders sentenced to

borstals or detention centres. Experiments should bemade in allowing borstal boys to undertake communityservice. The Bow Group has submitted Mr. Wilde’smemorandum to the Home Secretary’s Committee on

the Penal System, in the belief that, unless reforms aremade along the lines suggested by Mr. Wilde, then thecrime-rate will grow even more rapidly than in thepast few years, bringing the possibility of a breakdownin law and order on a scale hitherto unknown.

PREVENTION OF EPILEPSY

EPILEPSY can begin at any age, from the convulsionsin the newborn due to hypoglycaemia or meningitis toepilepsy starting in old age due to a tumour or thelate effects of cerebral infarction. Once the first fitis diagnosed, prevention is usually easy, by means ofthe battery of anticonvulsant drugs now available.Only a few patients prove refractory to drug therapy,and a small proportion of them require some surgicalapproach such as the excision of a cortical scar or of thetemporal lobe. In a few cases, intractable epilepsy haswarranted the heroic operation of hemispherectomy,which seems now to be justified only in a patient withsevere infantile hemiplegia and epilepsy. Section of thecorpus callosum has been performed in some patientswith intractable epilepsy in an attempt to prevent thespread of seizures which begin in one hemispherebecoming generalised. Though such an operation mayoccasionally be of benefit, it has produced more interestin relation to the disconnection syndromes that result.

Epilepsy may damage patients in a number of ways,including burns from falling into fires and injuriesfrom falling from heights or into machinery. Pro-

longed hypoxia may cause diffuse cerebral damage, ormore specific damage to areas of cortex in a watersheddistribution or to the cerebellum and hippocampus.These complications are to a large extent preventable.Care of the airway in the fit, and the emergency treat-ment in hospital of status epilepticus, can preventmuch of the danger of hypoxia. Patients should notwork at heights or with dangerous machines.The question remains: is epilepsy itself, in its many

forms, preventable ? Children of parents with idio-

pathic epilepsy carry a risk of developing epilepsywhich is probably several times that of the generalpopulation, though the risk is still slight. In a fewfamilies the risk seems to be higher. Genetic counsel-ling in such families may prevent the birth of a numberof children in the high-risk category. Febrile con-vulsions may be preventable (after the first fit) bytreatment of any fever with antibiotics and aspirin. Ifall the hazards to the newborn baby around the timeof delivery and in the months thereafter could be

prevented, there would be far fewer spastics and men-tally retarded children in our special schools, andfewer epileptics in these schools and colonies. Muchof the effort of the obstetric service in the past fiftyyears has been aimed along these lines, and the de-creasing size of epileptic and spastic populationsindicates the success that is being achieved. An articleon p. 1136 by Dr. Taylor and Dr. Bower reviewsmany of the factors which are potentially preventablein epilepsy. They also emphasise the importanceof preventing the negative secondary effects of epilepsy-that is, the over-protection of a child and thesocial stigma attached to epilepsy.