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Sterilisation of Instruments

We might borrow from industry here, and pass thesteel instruments-with the possible exception of knives-through an induction furnace. In two seconds the whole

instrument-every molecule of the instrument-wouldsimultaneously reach the required sterilisation tempera-ture. The conveyor belt would then carry the instrumentinto a cooling fluid so that it would be completely sterileand cool within ten seconds. Such a steriliser could be incontinuous use alongside the operating-table and yetnot radiate any perceptible heat or steam. This wouldadvance the aseptic ideal-that each instrument is usedbut once, then discarded. In a slightly pressurised theatrethe basin steriliser could be heated to some degrees above100°C without boiling, thus preventing excess water

vapour being discharged into the theatre.

Antisepsis of Personnel

Asepsis of personnel is impossible, but every effortshould be made to keep organisms from being shed intothe theatre atmosphere.

1. All theatre workers could have a spray in the airlock toremove desquamated skin.

2. After drying, a complete rub over with a cloth dampedwith a mildly antiseptic oil-to prevent further shedding ofepithelium and to cover the body with an antiseptic film.

3. It has been shown that carpenters working with hard woodhave sterile hands. Resins and oils in wood may account forthis. If bare hands, well washed before an application of anti-septic resin or oil, were used at operation rather than rubbergloves (which tend to cause sweating and concentration oforganisms) there would be less likelihood of tissues beinginoculated with an infectious concentration of microorganisms.When a glove is punctured the resultant spillage is a highlyconcentrated bacterial emulsion, which the tissues are less

likely to resist than the continual shedding of small numbers ofmicroorganisms from the bare hand.

Theatre Garments

Theatre fashions tend to protect the wearer rather thanthe patient. Long loose skirts blow the wearer’s des-quamated epithelium about in clouds at every movement,while floppy, clumsy, rubber theatre-boots are hot to

wear, cause sweating, and puff out foot dust at everystep. To lessen the effect of flapping clothes, suitabletheatre dress might be drainpipe slacks (fitting closely atthe ankle), close-fitting singlet with short sleeves, socksand ballet shoes, or sandshoes. Sterile dress: short, close-fitting, elastic jerkin with long sleeves tight at the wrist,tying at the back, with elastic round the trochanters. At

present, because of voluminous garments, surgeons andnurses often touch non-sterile objects without beingaware of doing so.

All the above may seem too fantastic and unrealistic,but researchers went to far greater lengths to producesterile rats (Davey 1959), and in I.C.I. laboratories a moreexacting. aseptic ceremonial is enforced even to see thesedisease-free rats.

Conclusions

To be successful the technique of asepsis must behighly efficient. This is impossible with modern operat-ing-theatre design, ventilation, and discipline; and, unlessthe technique is beyond criticism, it might be safer torevert to antisepsis. In a theatre suite as outlined, anaseptic technique could be practised that would at leastapproach perfection.

Further advances will more and more depend on extra-

corporeal blood pumps and oxygenation, and it is morethan likely that blood substitutes will be used for oxygencarriage, in which case pressurised theatres will be anecessity (Boerema 1961, Boerema et al. 1960). Existingtheatres cannot be modified for pressure, so that pres.surised theatres in future would have to be specially built.With prefabrication and standard design, it is possible

that a steel theatre would entail less capital expenditure.It would be more durable than stone or lime and plaster.If clean wound sepsis were reduced even by half, theshorter stay in hospital of patients would easily outweighcapital expenditure.

I am grateful to Prof. J. W. Howie, Bacteriologist, GlasgowWestern Infirmary, for advice and encouragement; and to WilliamGallacher for his excellent drawing.

REFERENCES

Bert, P. (1878) C.R. Acad. Sci. 87, 782.Boerema, I. (1961) Surgery, 49, 291.

— Meyne, N. G., Brummelkamp, W. K., Bouma, S., Mensch, M. H.,Kamermans, F., Stern Hanf, M., Aalderen, W. van (1960) J. Cardiov.Surg. 1, 133.

Davey, O. G. (1959) Discovery, 216, 469.J. Inst. Hyg. Vent. Engrs (1959) 26, 257.Tindal, A. (1941) Surgo, 7, 33.

MEDICAL RESEARCH

THE Medical Research Council had its beginnings inthe world of fifty years ago in which the value of scientificresearch was suspect. Now that the need for suchresearch is taken for granted, the Council’s role has

changed. Its latest annual report 1 discusses the presentfunctions of a central research organisation. The Councilsees itself as the coordinator of resources on a nationalscale. Working in partnership with other establishments,it supports judiciously selected research projects. In

making this selection, it must bear in mind the country’sprobable future needs; but it must never allow thisdirection of aim to become so rigid that individual workersare unable to act on their own initiative. The Council’sstatus as an independent body, advised by a widelyexperienced board, fits it to provide opinions which canbe trusted by Government and public alike.Some of the work supported by the Council is reviewed

in the report.Brain Mechanisms

A technique for injecting drugs painlessly into the cerebralventricles of unanxsthetised animals is being used to explorethe physiological basis of some of the physical symptoms ofmental disorder. Some drugs-e.g., adrenaline, noradrenaline,and calcium chloride-which have an excitatory effect whengiven systemically are depressants when introduced directlyinto the cerebrospinal fluid: the animal shows a disturbance ofconsciousness similar to sleep or anaesthesia. Some establishednarcotics (chloral, chloralose, and magnesium chloride) havethe same effect when given intraventricularly in very smalldoses. Sleep is sometimes preceded by compulsive eating, theanimal often falling asleep at the dish of food. This is believedto be due to the drugs’ effect on the hypothalamic centrescontrolling appetite.

Catatonia or hallucinations reminiscent of schizophreniafollow the introduction of acetylcholine or diisopropylfluoro-phosphonate (D.F.P.) into the ventricles: the animal maintainsunnatural postures, although it is not paralysed, for, whendisturbed, it can move normally. D.F.P. produces acute

attacks of psychosis in schizophrenics; but the disease is notnecessarily due to the persistence of acetylcholine at some

brain locus. All that can be concluded is that such persistence,1. Report of the Medical Research Council for the year 1960-1961.

H.M. Stationery Office.

243

by prolonging depolarisation, reproduces the neuronal damageand dysfunction of schizophrenia. In the cat, the introductionof D.F.P. into the ventricles may be followed by the complicatedcoordinated movements of washing, licking, and scratching.Mental Disorder in Old AgeThe high incidence of mental disorder among people over

65 has prompted the Council to inquire into the contributingaetiological factors. The importance of the problem wasemphasised by a report from Durham. Of three hundred andsix people over 65, randomly selected, 10% had definablepsychiatric illness.

Affective disorders in old age are often attributed to arterio-sclerotic senile dementia. The underlying neuropathology hasbeen clarified to some extent by a survey of three hundred con-secutive cases, in which the clinical diagnosis was comparedwith the postmortem findings. In about 75 % of those diagnosedas affective or paranoid, cerebral changes-senile plaques,neurofibrillary changes, or evidence of vascular disease-were slight. In a similar percentage of those diagnosed asarteriosclerotic, the pathological changes were moderate orsevere. But in the remaining 25%, clinical and postmortemfindings could not be reconciled, and the degree of this " over-lap " increased in the older age-groups.An investigation of schizophrenia of late onset showed that,

although the risk of the disease developing in collaterals washigher than among the general population, it was not as great asthat found for the first-degree relatives of patients who developthe disease before 60. Thus, environmental, rather than genetic,

factors seem to be important; physical illness, incapacity, andpoverty were common among these patients.Dental Caries

Dental caries has also been studied in detail. The preciseaetiology of the lesions has still not been clarified, but theessential role of purified fermentable carbohydrate in combina-tion with bacteria has been confirmed. The carious agent first

penetrates the enamel along the " incremental strix " formedduring growth of the tooth. A soluble fraction of the organicmatrix is then destroyed and decalcification follows; finally,bacteria invade the spaces so formed. Now that this sequencehas been established, it may be possible to attack caries bysomehow rendering the soluble organic matrix insoluble, or bypreventing the developmental faults along which the cariousagent first penetrates.Air Pollution

Since the dramatic fog of 1952, the Council has studied airpollution, with especial reference to chronic bronchitis andlung cancer. In a busy street in calm weather, the concentrationof carbon monoxide in the air may exceed that regarded as safefor 8 hours’ industrial exposure. Moreover, urban air containsappreciable amounts of nitrous oxide, whose affinity for hxmo-globin exceeds that of carbon monoxide. The concentration ofthe carcinogen, 3:4 benzpyrene, in the air of the BlackwallTunnel has been found to be no higher than that in Londonstreets on a foggy day. The operation of the Clean Air Actshould provide an interesting epidemiological situation whichthe Medical Research Council is prepared to exploit.

Medicine and the Law

Psychotic Delusions in Matrimonial SuitsA HUSBAND and wife were married in 1956, when the

husband was 41 and the wife 34. The marriage was neverhappy, but they continued to live together until January,1960, when the wife, after an attempt at suicide, was takento a nursing-home. Subsequently the husband petitionedfor divorce on the ground of cruelty. The wife denied

cruelty and pleaded that if she had ill-treated the husband,she was not responsible in law in that she had a defectof reason due to disease of the mind, and did not knowthe nature or quality of her acts or that what she did waswrong.The wife had accused the husband of being more interested

than he should have been in other women. He told her that heraccusations were unjustified, as was the case, but she persistedand in the autumn of 1959 accused him of a wrong relationshipwith another woman and of homosexual relations with threetenants of part of the matrimonial home. She also taunted himwith having married her for her money. At the end of Novem-ber, 1959, without any provocation, she kicked him sharplywhile in bed. By that time she was accusing him, their tenants,and the cleaner of being in league against her. DuringDecember, 1959, she assaulted her husband twice. On Jan. 2,1960, she attempted suicide, being saved from death only bythe arrival home of the husband. Thereafter, she was treatedin a nursing-home for some weeks.Mr. Justice ScARMAN said that, on the medical evidence,

he was satisfied that from September, 1959, until Jan. 2,1960, the wife had a paranoid psychosis, the effect ofwhich was that she had delusions centring on her hus-band, whom she saw as a hostile figure conspiring withothers against her. But save for her delusions she was arational being, able to distinguish between right andwrong. It followed that her responsibility at law-

assuming, as the Court must, that the McNaughten rulesapplied-was to be determined as though her delusionswere true. As she did not know; when she made the

accusations, that she was doing wrong she was not respon-sible in law for them. When, however, she used physicalviolence towards the husband, she knew that what shewas doing was wrong. Certainly the converse, that shedid not know, had not been established. The assaultswere intended to hurt the husband and did so; they couldproperly found an apprehension of future injury. Theytherefore constituted legal cruelty and the husband wasentitled to a decree nisi of divorce.

Elphinstone v. Elphinstone—Probate, Divorce and Admiralty Division:Scarman, J., May 3, 1962. Counsel and solicitors: David Karmel, Q.C., andH. S. Law (Braby & Waller); G. H. Crispin, Q.C., and D. R. Stuckey(Culross & Co.).

DONALD ELLISONBarrister-at-Law.

The Unregistered DentistAN unregistered dentist was acquitted at West Ham

Quarter Sessions on each of nine charges of unlawfulpractice. 1

These alleged that he had three times taken impressions ofthe mouth and jaw, four times inserted and fitted dental fix-tures, once assisted with a filling, and once examined a patient’smouth. Four patients testified to these charges, but agreedthat a registered dentist was working with the accused and thatthe standard of dentistry had always been satisfactory.The accused dentist said that for eight years he had worked

on a percentage basis with a registered dentist. He acted aschair-side assistant, doing the technical and clerical work.The Recorder, Mr. Walter Raeburn, Q.c., said that the

Dentists’ Act was ambiguous; it required dental surgery to bedone under the supervision of a registered dentist and inaccordance with conditions approved by the Minister of Healthand the General Dental Council, but these conditions hadnever been defined. The difficulty lay in drawing a distinctionbetween major and minor dental work. Mr. Raeburn held thatsurgery was the essence of dentistry and that the rest was

minor. All the procedures mentioned in the charges were inthis minor category and therefore permissible under the Act.

Prosecuting Counsel asked that the Recorder’s decision besubmitted to the High Court for an opinion.

1. Guardian, July 26, 1962.