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improvement, but long-term improvement was rare. Inclinical trials was it important to measure the effect, notonly of drugs, but also of the environment and otherfactors which tended to produce recovery.

Dr. R. HODGKINSON (U.S.A.) thought that the methodsof clinical evaluation used in Great Britain and in theU.S.A. were essentially the same. The pillars of clinicalevaluation were careful planning, systematic observationand performance, and honest and courageous interpreta-tion of the results. In America clinicians, even in smalland isolated hospitals, were very research-conscious.Another difference was that there was no official body inGreat Britain which corresponded to the Food and DrugsAdministration. He thought that the clinician in chargeof clinical trials should himself take the maximal dosewhich was to be used in volunteers in clinicopharmaco-logical studies, and it was most important that the resultsof controlled clinical trials should be available before thedecision to market a product was taken.

Dr. M. HAMILTON referred to the placebo response,which was of considerable importance in controlled

investigations. Studies at Leeds had shown that therewas no relationship between the patient’s age, sex, or

personality and his response to a placebo. The evidencedid not support the concept of a placebo reactor andnon-reactor.

Dr. A. A. BAKER emphasised the inherent difficultiesof double-blind investigations. In his experience, rarelywas it possible to conceal from the patient for more thana few days which was the active and which was the inertdrug. Patients were generally able to distinguish easilythe active drug by its subjective effects.

In his summing up Sir GEORGE PICKERING said itwas praiseworthy that such a meeting should have beenheld under such auspices. The level of clinical andscientific integrity which had been achieved was high.It was most important in clinical evaluation that the rightquestion should be posed and that the answer obtainedshould be to that question. For instance, because a

substance lowered the blood-cholesterol level, it did notnecessarily follow that this was of use in the treatment ofatherosclerosis. He believed that one of the functions of a

good physician was to produce in the patient a placeboeffect. After all in his youth, not so long ago, that was theonly criterion distinguishing a good from a bad physician.

HOSPITAL CROSS-INFECTION

IT is a sign of the times that a conference on theprevention of hospital cross-infection should have beenconvened by the regional board at Little Bromwich

Hospital, Birmingham, on Jan. 16 under the chairmanshipof Prof. JOHN SQuiRE. Significantly the conference washeld in a hospital which until a few years ago was a feverhospital but which changed its character because of adearth of patients; and ironically the delegates came tothis erstwhile fever hospital from the fever hospitals oftoday-the general hospitals. The staphylococcus, thoughthe principal villain paraded on the stage, was not withouta supporting cast.

Description of Outbreaks

Dr. KBITH ROGERS (Birmingham) described epidemicsin a children’s hospital. These fell into three main

groups: virus infections (in particular measles); infection

with gram-negative bacilli; and infections with gram-positive cocci. He had found that the presence of oneEscherichia coli carrier in a ward of patients with pneu-monia would result in an infection-rate with this organismof 45%, thus extending the stay in hospital of each casefrom two weeks to thirty days or more; similar resultswere obtained from a series admitted for intussusception.After screening of every admission and separation of

patients free from the organism from those excretingEsch. coli, enteritis had developed in only 9 of 137 casesof pneumonia. In his hospital, though infection spreadreadily on one floor, there was no spread vertically toother floors; this might be due to the movements

of nursing staff, which were usually restricted to one

level. In the summer months they had had to face amystifying and serious outbreak of Pseudomonas pyo-cyanea infection, sometimes fatal, in patients with tracheo-bronchial fistula. The facts that in all the cases the patienthad been operated on and the infection was not confinedto one ward led the search for a source to the theatre,where ultimately a repository for a bronchoscopic suckerwas found to be heavily contaminated. When this sourcewas eliminated the epidemic ceased, but it recurred laterowing to a concatenation of circumstances which broughtabout the return of the sucker and its sheath. Dr. Rogershad recently brought a staphylococcal epidemic undercontrol after discovering that 6 out of 8 nurses with pimplesand boils were carriers of phage-type 80.

Preventive Measures

Dr. W. A. Gillespie (Bristol) said that the colonisationwith staphylococci of babies newly born in hospitalshould be delayed for as long as possible in order toprevent frank infection. With this in view he hadattacked the blanket problem in nurseries and had

arranged for chlorhexidine hand-cream to be used by thenurses. By using hexochlorophane as a dusting-powderhe had prevented colonisation of the umbilicus, groin, andperineum but not the nose, for which he thought anointment necessary. As a result of these measures theincidence of sepsis fell over two years to 0-8% from

7% in one nursery and from 9% in another for all babiesretained during a ten-day period. He had seen no

allergic sensitivity to hexochlorophane even when thiswas used in the bath-water. Other investigations he hadundertaken concerned urological cases. After prostatec;tomy the incidence of urinary infection fell to 57% whenclosed drainage was used, to 23% when the operatingcystoscopes were swabbed with chlorhexidine, and to 8%with preoperative urethral disinfection. 69% of cases ofretention had urinary infection following open catheter- drainage and 8% following closed drainage.

Infection in the Theatre

Dr. EDWARD LOWBURY (Birmingham) said that theincidence of infection in clean operation cases was rising:figures now reported were as high as 15-20%. Theinfection was usually staphylococcal, and only rarelytetanus or gas-gangrene. He found that 20% of surgicalwounds were contaminated by the act of incision, andthat 60% were infected by the end of the operation.Airborne contamination with staphylococci came from asource inside the theatre, with tetanus or Clostridiurnwelchii from outside. The factors leading to contaminationwithin the theatre were numerous. He recommended forthe patient’s skin 1-2% iodine in 70% alcohol, and for

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the surgeon’s hands hexochlorophane soap followed by ahalf-minute rinse in 70% alcohol and the possible use ofneomycin-bacitracin glove powder to reduce contamina-tion from the hands through holes in the gloves. Experi-mentally he had found that the bacterial count fromhands covered with defective gloves but no powder wastwenty times greater than when neomycin-bacitracin pow-der was used. Using slit samplers he had shown how aircontamination builds up with movement within a badlyventilated theatre, whereas summation of each incidentof increased air contamination does not take place whenventilation is corrected. By similar techniques he hadcorrelated the concentration of air contamination due to

poor ventilation with the infection-rate iri a dressing-station for burns. In answer to a question, Dr. Lowburystated that further work was needed on solutions for thesterilisation of sharp instruments since neither lysol,carbolic acid, the phenolics, nor chlorhexidine in alcoholcould be guaranteed to destroy spores, though theaddition of formaldehyde to a chlorhexidine-alcoholsolution might suffice. Another speaker pointed out thatthere was no objection on metallurgical grounds to boilingor steam sterilisation of sharp instruments.

Blankets

Dr. ROBERT BLOWERS (Middlesbrough) described thesweep-plate technique for investigating blankets, thecontamination of which (commonly with Staphylococcusaureus, Ps. pyocyanea, and Esch. coli) becomes worse aftersimple laundering. Proof through phage-typing had notsimple iaundering. Proof through phage-typing had notbeen obtained of infection by one patient of the next tooccupy the same bed, but blanket contamination

undoubtedly spread infection less directly through inter-mediate agents such as a nurse’s or doctor’s hands orclothes. Woollen blankets might be rid of non-sporingorganisms by immersion at 70°C, but agitation of thewater damaged the blanket. Blankets could be sterilised

by steam at 5 lb. pressure or by heating in an atmosphereof formaldehyde vapour-a laborious process. Theycould be made hygienically clean by washing and thendisinfected with quaternary ammonium compounds-though this is not effective against gram-negative organ-isms. Though detached fibres of the blankets thus treatedcould then be seen to inhibit other organisms, the blanketson beds had no such effect, probably because of drying.After 20 such washes the blankets were too shrunken andhard for comfort; but the number of washes could beextended to 60 after the application of devices to minimiseshrinkage. Until a feasible method of sterilising woolwas found it was easier to turn to other materials.

’Terylene ’ was unsatisfactory since the " woolly " fibresbecome matted after repeated boiling: it also developed ahigh static charge with serious spark hazard. Probably thebest material at present available was cotton in open orcellular wove; this was light and boilable, though suscep-tible to damage by tumbler-drying. Turkish-towelling,being cotton, was also boilable and hard-wearing;Calnan-mesh, a design based on string-mesh sandwichedbetween sheets of cotton-rayon mixture, was heavy,inflexible, and tedious to wash and dry. Dr. KEITHTHOMPSON (Birmingham) had found that after 40 washescotton blankets were still within 12-15% of the thermalefficiency of woollen ones. It was suggested that woollenblankets might be sterilised by subjection to radioactivity,but it seems that this caused disintegration after a fewapplications.

Carriers of Infection -

Dr. ROBERT WILLIAMS (Colindale) declared that 50%of hospital staffs are nasal carriers of staphylococci and20-25% of adults become so after 3 weeks in hospital.Besides the nose, the perineum was a potent source ofcontamination. Those most liable to colonisation by thestaphylococcus on admission to hospital were those whowere not nasal carriers before admission; carriers showedsome immunity. Resistance to tetracycline rose to 100%after the drug had been administered for a week. The

development of penicillin-resistant strains in a woundwas due to cross-infection with resistant organisms, sinceit was unlikely that strains sensitive to penicillin couldthemselves become resistant-though erythromycin resis-tance did develop in this way. In answer to a question,Dr. BLOWERS emphasised that any member of the nursingor medical staff who developed a pimple or boil shouldbe relieved of duties bringing him or her into contact withpatients until the bacteriologist permits return to duty;and it should be borne in mind that the scar or crust atthe site of a recent pimple still harboured many organisms.

The Pathologist’s Role

Dr. KEITH THOMPSON (Birmingham) described therole of the hospital pathologist as that of hospital police-man who, by the exercise of intelligence and observation,could do much to mitigate infection through simplemeasures in outmoded buildings and with outdated

apparatus in theatre, kitchen, and ward. Air currentscould be deflected, cooking practices and the handlingof food be kept to a high standard of hygiene, and wardsepsis reduced by such simple measures as the avoidanceof overcrowding and the oiling of floors. Simple instruc-tion in bacteriological principles to kitchen and otherstaff was obligatory and was appreciated by the staff. Theresponsibility lay with the doctor-primarily with thehospital pathologist.

Dr. W. H. BRADLEY (London) reiterated that the

responsibilities involved in avoiding cross-infection shouldbe defined.

1. Western Mail, Jan. 24, 1959.

Medicine and the Law

Death Following TonsillectomyAT an inquest in North Wales on Jan. 23 the jury

returned a verdict of " death aggravated by lack of care "in the case of a 5-year-old who had died in hospital theday after tonsillectomy.The surgeon who operated on the boy said that after the

operation, at 12.30 P.M., his condition was satisfactory. At10 P.M. the surgeon received a report that the boy had vomitedblood and had a rapid pulse-rate of 168, but there seemed tobe no further bleeding. He asked to be informed if the pulse-rate did not settle down, but he received no further message.A nursing sister said that at 9 P.M. on the evening of the

operation the boy vomited blood, and she called another doctor,who treated the boy; his condition improved. She checked thepulse half-hourly, and at 5 A.M. he was chirpy and asked for hisbreakfast. She gave him orange juice. Later she saw that thechild’s condition had deteriorated; the pulse-rate did rise, butnot above 168, at which level it was when the doctor called at9 P.M. and first took it.A pathologist gave evidence that death was due to heart-

failure resulting from reactionary haemorrhage.