530

the presence of Gram positive organisms on culture " ’.the organisms are not specified. In these cases,

however, cultures of sputum rarely contain no gram-positive organisms at all; and thus penicillin therapywould be indicated almost always in chronic bronchitisor bronchiectasis where the sputum is purulent. Yet

experience has shown that only some cases are

benefited by penicillin, administered either by inhala-tion or by intramuscular injection. BARACH and his

colleagues report that penicillin by inhalation caused" marked or moderate " improvement in 58 out of70 cases of bronchiectasis, 46 out of 50 cases of chronicbronchitis without clinical evidence of broncho-

spasm, and 97 out of 200 cases of chronic bronchitisassociated with bronchial asthma. At first sightthese figures may seem encouraging, but unfortunatelyin 20% of patients with bronchitis and asthma theinhalations increased wheezing so much that thetreatment had to be discontinued. It appearsthat penicillin administered intramuscularly to thesepatients gave less benefit than inhalations. Onereason for this was that with inhalations the con-centrations of the antibiotic in the sputum rangedfrom 50 to 2000 units per ml.-a range high enoughto swamp many organisms not normally regarded assensitive to penicillin. BARACH et al. remark that thisapplied to many apparently penicillin-resistant staphy-lococci. It may also have applied to Hœmophilusinfluenzœ—a gram-negative organism which MULDERet al.15 believe to be the most significant pathogen inall types of respiratory infection.The studies by BARACH et al. of the effects of the

broad-spectrum antibiotics on chronic bronchitis andbronchiectasis shed little new light on the role ofdifferent organisms in these diseases. As with peni-cillin inhalations the clinical responses were encourag-ing. " Marked or moderate improvement, as judgedby cough, expectoration and clinical well-being," wasobserved in 26 out of 31 cases of bronchiectasis andin 37 out of 45 cases of chronic bronchitis. But the

changes in the bacterial flora of the sputum in casesimproved by this therapy do not seem to have followedany consistent pattern. BARACH et al. apparentlyattach great importance to Staphylococcus aureus. Thiswas present in the sputum of 11 patients after therapy ;yet the condition of 9 of these had been improvedconsiderably. Similarly each of 7 patients in whosesputum Friedlander’s bacillus was found after therapyhad been greatly improved by treatment. With

regard to the pneumococcus, however, there was

closer correlation between clinical improvement anderadication of the organism : pneumococci were

present in the sputum of only 2 patients after therapy ;in neither of these had definite improvement beenobserved, but the eradication of pneumococci fromthe sputum of 15 other patients was in each caseassociated with improvement. The pneumococcushas been found to be distributed intermittently inthe sputum 13 - and this organism may have been

present, but not detected, in the sputum of some ofBARACH’S cases where clinical improvement could notbe correlated clearly with changes in the bacterialflora. This is important, since the antibiotic ofchoice in such cases would always be penicillin,intramuscular injection of which would be adequate15. Mulder, J., Goslings, W. R. O., van der Plas, M. C., Lopes

Cardozo, P. Acta med. Scand. 1952, 143, 32.

and free from the side-effects that may accompany theuse of the broad-spectrum antibiotics. The need for

avoiding unnecessary use of the broad-spectrum anti-biotics is once again evident from the fact that inthe 76 cases of respiratory infection treated with theseby BARACH et al. there were no fewer than 7 deaths,all of which were ascribed to the development ofinfection by organisms highly resistant to all anti.biotics.

1. Mottram, V. H., Graham, G. Hutchison’s Food and thePrinciples of Dietetics. London, 1948 ; p. 255.

2. Illingworth, R. S., Stone, D. G. H., Jowett, G. H., Scott, J. F.Lancet, 1952, i, 683.

3. Kleitman, N. Physiol. Rev. 1949, 29, 1.4. Kennedy, G. C. Proc. roy. Soc. B. 1953, 140, 578.5. Anand, B. K., Brobeck, J. R. Proc. Soc. exp. Biol., N.Y.

1951, 77, 323.6. Hutchinson, R. C. Nutr. Abstr. Rev. 1952, 22, 283.7. Bergin, K. G. Aviation Medicine. Bristol, 1949; p. 79.

Mealtimes

EATING, besides satisfying a physiological need,reflects a psychological state, as in the overeating ofthe emotionally deprived and the anorexia nervosa ofthe despairing. It has also a religious symbolism;while communal meals and ceremonial feasts make forsociability. The body likes a- rhythm of recurringmealtimes but is less particular about the tune. Thetraditional Englishman starts his day with a goodbreakfast of porridge and bacon and eggs, and laterhas a light lunch. The Frenchman living in a similarclimate goes to work after a cup of coffee and a roll,but lunches substantially. Kaffirs prefer to wait fortheir big meal till evening, when the heavy labour isfinished. 1 Babies fed whenever they cry for foodusually establish their own timetable of feeds every3-4 hours.2 Hunger probably reflects internalmetabolic rhythms,3 about which little is known 4 ;and, like other biological rhythms such as sleep, itcan be modified by training. There are said to be

separate hunger and starvation centres in the hypo-thalamus, at least in white rats and cats 5: destroy onecentre and the animal overeats to extreme obesity,destroy the other and henceforth it refuses all food.Under more or less natural conditions the healthy

man need not bother about all this : his stomach willtell him when to eat. Modern industrial life, however,is far from natural, and the relation between workingperformance and frequency of meals is of interest tofactory managers, and also to athletes, schools, andthe Services. If the worker’s blood-sugar level beginsto drop towards the end of a shift, perhaps an interimsnack would stay this decrease and maintain his

output ? Unfortunately, HUTCHINSON, 6 from hisreview of published work, mainly American, concludesthat with the possible exception of breakfast the

ingestion of food is not followed by an increase inindustrial productivity or improvement in athletic

performance : indeed, a large meal may impair both,since it causes drowsiness and lack of coordination.Yet we know that long periods between meals maygive rise to restlessness, irritability, and diminishedconcentration ; and HUTCHINSON goes so far as to

suggest that efficiency may be greatest with small butfrequent meals, numbering as many as six a day.In research of this kind it is very difficult to dis-

entangle the physiological effects of meals from thepsychological value of the accompanying rest pauses.particularly when these break the monotony ofrepetitive work. (BERGIN 7 advises meals every two

531

hours for air passengers, almost solely to break themonotony of long journeys.) Nor is it easy to distin-

guish short-term effects from those resulting moreslowly from a gradually changing biological rhythm.MAGNUS PYRE 8 points out that the hours of shiftwork in themselves affect a worker’s daily meal

pattern, since even if he eats on the job he also likesto eat at home. Night shifts change meal patterns inan extreme way, and the nature of the work also

plays a part. Really heavy work at the coal facedemands additional calories ; and when and howthese are to be provided depends on individual con-ditions-whether the man crouches at his work, hisshift times, the distance of the canteen from thecoal face, the eating customs of his people, andso on.

Invalids, on the other hand, and especially those inhospital, live under more nearly standard conditions ;and new work in the U.S.A. suggests that we still

8. Pyke, M. Industrial Nutrition. London. 1950.

have much to learn about restoring the convalescentinvalid’s appetite to normal. Experimentally it hasbeen found that rats can be trained to eat three timestheir normal diet if any food left uneaten is removedat once ; and KEETON 9 has successfully applied thisform of appetite training to patients. They are

started on a single large meal a day ; this is given inthe morning, and anything uneaten is removed. Ifthey feel hungry later in the day they must still waittill 8 A.M. before receiving more food. When they areeating all their food they are started on a second mealevery day at 4 P.M., and they are finally promoted tohaving a third at 10 P.M. In this way KEETON has

persuaded patients to double or even quadruple theirdaily calorie intake. It will be interesting to see

whether this method can be generally applied, andwhether the food intake of the obese can likewise be

painlessly lowered by offering small quantities of foodall the time until the patient hates the sight of it.

9. Keeton, R. W. J. Amer. med. Ass. 1953, 151, 253.

Annotations

CHILDREN IN HOSPITALTo be civilised seems, at times, to consist in learning

to do consciously what natural man does instinctively.Xo savage needs to be told that separation from themother damages young children, because his youngchildren spend their entire time with their mothers asa matter of course. We, on the other hand, introducethe young child into a highly complex society, and inattempting to fit him for it find a hundred good andconvenient reasons for parting him for longer or shorterperiods from his natural collaborator ; and we have

only lately come to see that it does him no good. Evidencehas been accumulating for some years now that childrenin hospital suffer psychologically unless they are visitedoften by their parents ; but an astonishingly largeproportion of hospitals have chosen to ignore such

findings. A Ministry of Health inquiry, made last year(p. 539) showed that only 300 out of 1300 hospitals takingchildren were allowing daily visiting ; and 150 prohibitedthe visiting of children altogether. The Ministry’srequest that all hospitals should allow daily visitingof children is thus not only wise but necessary. Hos-pitals which have already adopted the plan have notfound it impossible or even specially difficult to

administer ; and they agree that it has been beneficial.Xurses are often credited with resisting the principleof daily visiting on the grounds that it upsets the children :and it is true that the moment of departure of the mothersis usually a time for tears. But nurses are reasonable

people, willing to learn. A few set lectures puttingthe known facts before them would change their outlook,and help them to accept the tears as part of a normalemotional reaction. Once they are convinced that a

thing is good for their patients they support it : that istheir great virtue.

1. Winterscheid, L. C., Mudd, S. Amer. Rev. Tuberc. 1953, 67, 59.2. Brieger. E. M., Cosslett, V. E., Glaubert, A. M. Nature, Lond.

1953. 171, 211.

TUBERCLE BACILLUS UNDER ATTACKSTREPTOMYCIN and isoniazid appear to have different

(-fleets on the growth of tubercle bacilli. Electron micro-

scopy has shown that normally the bacilli grow to upto seven times their original length in twenty-four hours,and there appear two dense polar bodies which are saidto resemble the mitochondria of the cells of higherorganisms in appearance and cytochemical reactions.!After three days the uniform bipolar filaments havebroken down into individual rods. Brieger and his

1.()Ueat, nu eS 2 have found that in cultures containing

streptomycin the bacilli grow more slowly ; the filamentsare much broader and show less definite internal struc-ture, although the polar bodies still present often increasein size and become distorted. The mycelial tendenciesin some strains are exaggerated by streptomycin, andthe polar bodies become irregularly arranged. Isoniazidproduces very different results. Low concentrationshave very little effect, but with 20 µg. or more per ml.the rods of the inoculum do not elongate and indeedappear to shrivel and become less transparent. Laterthe culture seems partly to recover and filaments areproduced. Isoniazid has therefore an immediate inhibitoryaction, whereas that of streptomycin is delayed.

Possibly these complementary actions on the bacilli

might be one of the reasons for the good clinical resultswhen the drugs are used together.3 Brieger and hiscolleagues carried out their investigations on an

attenuated avian strain in Tween 80 medium, whichitself affects tubercle bacilli. Growth in certain con-centrations of Tween 80 causes virulent bacilli to behavelike non-virulent organisms and enhances the action ofmany inhibitory substances. Bloch and Noll 4 suggestthat Tween 80 causes " cord factor " to be secreted intothe surrounding medium ; the bacilli become lessvirulent in mice and give the positive methylene-blue test typical of avirulent tubercle bacilli and sapro-phytic mycobacteria. Similar changes occurred when thebacilli were cultured in one of the thiosemicarbazones ;but, although the bacilli became less virulent, cord factorwas not detected in the medium, and Bloch and Nollsuggest that the thiosemicarbazone had inhibited itssvnthesis.

3. Medical Research Council. Brit. med. J. March 7, 1953, p. 521.4. Bloch, H., Noll, H. J. exp. Med. 1953, 97, 1.5. Law, F. W. Brit. J. Ophthal. 1951, 35, 765.

READING TYPES

FOR a long time the reading types used by ophthalmo-logists to test near vision have been wandering furtherand further from the standards first suggested by Jaegar,and supposedly used ever since. The main reason forthis seems to be that the original founts from which thetypes were produced are now obsolete, so that, although theJaeger notation is still attached to many reading charts,this no longer has any real meaning, for different firmsprint the charts in different types and often, therefore,in different sizes. In 1951 Law 5 described the positionwith admirable clarity, made some recommendations ofhis own for improving matters, and, on behalf of thecouncil of the Faculty of Ophthalmologists, asked forsuggestions and comments. The council received sugges-tions from a number of sources, and they have now