1111

biotics suppress the antibiotic-sensitive commensal

organisms and favour selection of resistant speciessuch as Ps. œruginosa.5One group of patients who are liable to get Ps.

œruginosa bronchopneumonia are those with chronicrespiratory-tract damage-from cystic fibrosis, forinstance. 6 Ps. œruginosa appears rather late in thedisease, after the ground has been prepared byStaph. aureus and Hœmophilus influenzce. It is

notoriously hard to determine whether or not

organisms isolated from the respiratory tract are

pathogens. Isolation of an organism (usually in fairnumbers) from a purulent sputum and a promptchemotherapeutic response provide good clinical evi-dence,6 but interpretation of the results may be diffi-cult if the infecting organism is hard to eradicate.Precipitins or agglutinins in the serum to the infectingstrain may give a clue to pathogenicity because theysuggest tissue invasion. In one study, pseudomonas-specific precipitins were found in roughly a thirdof patients with cystic fibrosis.6 Such precipitinswere usually found when a mucoid strain of Ps.

œruginosa was present in the sputum. DIAZ et al. 7

found that mucoid strains tended to predominate inmoderately or severely ill patients. Moreover, allfour of their patients who died during the studyharboured mucoid strains. It is conceivable, there-fore, that certain metabolic conditions favour thesestrains. Serotyping yielded some interesting results.Three different serotypes tended to predominate inthe majority of the patients, and a third of the patientswere infected with more than one serotype. Long-term observation showed that, in individual patients,one serotype tended to persist, whereas other sero-types made transient appearances. A specific anti-body response occurred in the vast majority of

patients. Another study showed that when thetyping results were related to the antibiotic sensitivityof the different strains a most confusing picture couldemerge if the possibility of multiple infection or

changing strains was not recognised.Ps. ceruginosa bronchopneumonia has a character-

istic histopathological picture.9 Basically the lesionis a vasculitis. Large numbers of bacteria infiltratethe walls of arterioles and venules, and the intra-luminal inflammatory response is slight. Close to theblood-vessel there is a sparse inflammatory infiltratewith a diffuse necrosis. Ultimately the vessel wallruptures, causing haemorrhage into the adjacentalveoli. PIERCE et awl. and BARSON 2 have used thischaracteristic picture as an aid to establish the pre-valence of Ps. œruginosa pneumonia in necropsymaterial from adults and children respectively.

Prevention is more effective than treatment in the

5. Asay, L. D., Koch, R. New Engl. J. Med. 1960, 262, 1062.6. Burns, M. W., May, J. R. Lancet, 1968, i, 270.7. Diaz, F., Mosovich, L. L., Neter, E. J. infect. Dis. 1970, 121, 269.8. Darby, C., Keane, C. T. Cystic Fibrosis Research Conference.

Manchester, December, 1970.9. Fraenkel, E. Z. Hyg. 1917, 84, 369.

control of Ps. œruginosa bronchopneumonia. Becauseof the organism’s preference for moisture, particularattention should be paid to the disinfection of ventila-tors and incubators. Few antibiotics are effective

against Ps. œruginosa. The polymyxins (includingcolistin), gentamicin, and carbenicillin have all beenused singly 10,11 and occasionally in combination.The results have been varied. Carbenicillin has beensaid to act synergistically with gentamicin,12 but thishas been disputed.13 Ominously, there has been asteady rise in the resistance of Ps. œruginosa to carbeni-cillin, and LowBURY and his colleagues 1-1 have shownthat infectious resistance may arise in burns, so that ina mixed population of bacteria resistance to carbeni-cillin may be transferred from other gram-negativebacteria. Possibly this also happens in sputum.

VAGINAL ADENOCARCINOMA IN YOUNGWOMEN

EVEN large reference works pay little attention toadenocarcinomas of the vagina and devote most spaceto discussing their relationship to vaginal adenosisand the disputed histogenesis, whether mullerian ormesonephric. 15 This attitude has hitherto been

justified because of the rarity of these tumours, butnow that a cause has seemingly been identified inBoston this approach must change. In 1970 Herbstand Scully 16 described 6 cases in girls aged 15-22 yearsand reviewed a further case seen in Boston. All the

girls had had abnormal vaginal bleeding (thought to beanovulatory), and in 3 cases no abnormal cells wereseen in vaginal smea’s. Subsequently an 8th case wasfound, and all these have been studied in detail in aretrospective case-control study. 17That such a rare cancer should appear in a group of

young women in a particular locality suggested a

special environmental influence. The significantfindings were not only clustering for the tumour butalso clustering for time of birth. Investigation of thepregnancies that had produced the affected girls re-vealed a highly significant association with treatmentof the mother with diethylstilbrestrol from the first tri-mester of pregnancy.17 The drug had been givenbecause of previous fetal loss or abnormal bleed-

ing early in the pregnancy. In only one of the motherswas stilboestrol therapy not established, and allthe affected girls were born in the years 1946-51,when the use of oestrogens in high-risk pregnancybecame widespread, so the possibility of furthercases appearing is immediate, even though theindividual risk may be very small.The administration of oestrogens in early pregnancy

10. Hoffman, T. A., Bullock, W. E. Ann. intern. Med. 1970, 73, 165.11. Boxerbaum, B., Doershuk, C. F., Matthews, L. W. J. infect. Dis.

1970, 122, S59.12. Brumfitt, W., Percival, A., Leigh, D. A. Lancet, 1967, i, 1289.13. McLaughlin, J. E., Reeves, D. S. ibid. 1971, i, 261.14. Roe, E., Jones, R. J., Lowbury, E. J. L. ibid. p. 149.15. Evans, R. W. Histological Appearance of Tumours. London, 1966.16. Herbst, A. L., Scully, R. E. Cancer, N.Y. 1970, 25, 745.17. Herbst, A. L., Ulfelder, H., Poskanzer, D. C. New Engl. J. Med.

1971, 284, 878.

1112

must now be considered as a possible cause of vaginaladenosis (seen in 5 of the cases) and adenocarcinomadeveloping in the daughters up to twenty-two yearslater; and further cases, with an even longer pre-induction period, may come to light. Abnormal

vaginal bleeding in girls should raise a suspicion ofvaginal adenocarcinoma.

As Langmuir 18 suggests, stilbcestrol given to themother may in some way, and at an undeterminedcritical phase, affect the female infant’s urogenital tract,laying it open to the development of adenosis andadenocarcinoma years later. The long induction periodis striking; and whether early changes are detectable,how the mechanisms operate, and how the hormonal

pattern of the individual enters into the complexremain to be determined.

FAILURE TO COMMUNICATE

IN the wake of investigations at Ely Hospital, theSecretary of State for Social Services, Mr. RichardCrossman, agreed in March, 1969, that a new system ofregular visiting or inspection of such hospitals wasneeded. As a result, the Hospital Advisory Servicecame into being. In its first year it concentrated on

visiting hospitals for the mentally handicapped,hospitals for the mentally ill, and hospitals for geriatricand chronic sick patients, and the first annual report, 19which collects together general opinions and recom-mendations on the service provided by these hospitalsin England and Wales, has now been published. Itallocates the chief blame for the shortcomings in thehospitals visited to lack of communication at all levels-between hospital and community, between staff andpatients, between hospitals, management committees,and regional boards, and between regional boards andthe Department of Health and Social Security, andbetween the nursing, medical, administrative, andother staff in the hospitals. In many hospitals the staffinvolved in patient care had never all met together,even where Salmon and Cogwheel structures had beenestablished. Because mental-handicap and mental-illness hospitals often have catchment areas coveringup to a dozen local authorities, sometimes the meetingcalled by the visiting team of the Hospital AdvisoryService between the hospital and local-authority staffwas the first of its kind.

Though the report gives credit where it is due, itdoes not attempt to gloss over serious deficiencies inthe hospital service. Both mental-handicap andmental-illness hospitals suffer, it says, from being toolarge and too remote from towns; they are over-

crowded, understaffed, and sometimes lack essentialfacilities and equipment. Almost all hospitals of 1000beds or more were found to have serious problems in- providing anything like individual care for each

patient, a good communications system, or reasonablestaff morale. Staff in these hospitals often complainedto the visiting teams that they wanted some clear

guidance from the regional board and from the

18. Langmuir, A. ibid. p. 912.19. National Health Service Hospital Advisory Service. Annual Report

for 1969-70. Department of Health and Social Security andWelsh Office. H.M. Stationery Office, 1971. 27 1/2 p.

Department on the development of the service whichthey provided. Many regional boards were still addingto and refurbishing their old hospitals for the mentallyhandicapped and were making no attempt to establishmodern methods of care. The report also criticisesmanagement committees for taking only a cursoryinterest in their hospitals, for accepting withoutquestion the reports made to them by hospital staff,and for being afraid to suggest innovations. Theamount of emphasis put on social training in mental-handicap hospitals was a clear indication to the teamsof whether a hospital was running successfully or not,and they noted that where nurses were given authorityon the wards there was a significant improvement inpatient care.

Hospitals for the mentally ill were found to be mostsuccessful where the total service was broken downinto small units with mixed-sex wards. The visitingteam was worried, however, by the rapidity of in-stitutionalisation of many patients, who often passedfrom admission to long-stay wards within a matter ofdays. In these hospitals there was a noticeable absenceof effort towards rehabilitation and a lack of effectivefollow-up for discharged patients known to be at riskof relapse. Many regional boards had neglected toforge any links with local-authority and other facilities,on the pretext that it was necessary to wait for the

implementation of a new Act or publication of a newgreen-paper.

The team formed to investigate services for geriatricand chronic-sick patients found " gross and obviouscontradictions and extremes " in the care provided byhospitals. They noted that geriatrics was still not

recognised by many in the medical profession as a

separate specialty, and that there was considerableargument as to what came within the geriatrician’scompass. The result was that one hospital might haveone chronic-sick bed where another area would have a

hospital of nearly 800 beds given to the care of geriatricand chronic-sick patients. The visiting team wasconcerned at the inadequacy of the service provided forthese patients, and felt that it was more often than not areflection of the attitude of the senior staff and manage-ment in each hospital group, who believed that theneeds of the chronic sick were far less important thanthose of the acute patient. There were basic deficienciesin the service. For instance, the resources for caring forincontinent patients in the wards were quite unsatis-factory-nurses often had to deal with linen and

equipment by hand. The local authorities were to

blame, too, for failing to make provision for elderlypatients who need not have been in hospital. But the

geriatric patients in mental hospitals formed the mostdeprived group, the team found. They might havemultiple handicaps, but many mental hospitals haveno physiotherapist to provide rehabilitation servicesfor elderly patients. Another aspect of this problem isthat nurses with full psychiatric training find them-selves caring for elderly, physically frail patientswithout sufficient help; many become discouraged,and the difficulties of recruiting and keeping staff tonurse these patients are acute.

It is too early to judge the usefulness of the HospitalAdvisory Service, but the teams were much encouraged