1110

the forthcoming generation (the first to be affected bysuch action) will be starting to reproduce.

Suggestions regarding possible measures for dealingwith population growth are set out in the report as amemorandum from the Conservation Society. Theyinclude the widest possible dissemination of objectivemethods of birth control and easy access to impartialprofessional advice. " All boys and girls should havean accurate knowledge of contraception by the timethey leave school." And the young should be

acquainted with the various aspects of the world

population problem, for clearly it is going to affectthem. The Society also recommends that theNational Health Service should have overall responsi-bility for family planning and that the FamilyPlanning Act of 1969 should be made mandatory onlocal authorities. Better training in contraceptivemethods is advised for medical students and familydoctors, and sterilisation procedures should beavailable under the Health Service. Though criticalof the attitude of some doctors, the Society realisesthe need to enlist the cooperation of the medicalprofession, and its proposals clearly merit considera-tion by the profession and by Government.

Action by Government, local authorities, doctors,health visitors, and others is no doubt necessary, butit should not be overlooked that probably the chiefforce determining family size is parental motivation.During the depression of the 1930s, despite the

crudity of contraceptive methods then available, thebirth-rate fell not only in this country but, moresurprisingly, in France. People have to make a

population policy work and they can do so when theyrealise the necessity. A close study of what influencesthem in deciding family size is probably a first

priority. Already it is clear that the female partner isno longer content to be merely passive. She is

demanding (and obtaining) an increasing say inwhether or not she shall have a child-or anotherchild. This is a powerful and relatively new factorwhich could grow rapidly not only here but also indeveloping countries where its influence has hithertobeen slight. Granted the biological fact that it iswomen who have babies and bear the main brunt of

rearing them, it seems not unreasonable that theyshould be able to assert their viewpoint in andoutside the home with more emphasis than hitherto.Continuing a working career, especially with the

coming achievement of equal pay, should furtherstrengthen their position in determining family size.With the introduction of the contraceptive pill, morecontrol is already passing to the woman, and the

prostaglandins could greatly accelerate this trend.The doctor’s role would also be diminished.The Select Committee, which incidentally had no

women members, has provided another cue for publicdiscussion of this vital matter and it has put forwarda constructive and potentially fruitful suggestion.Indeed, so many responsibilities have been suggested

for the new Special Office that it could soon itselfbecome a Ministry. Certainly it should work in closecollaboration with other Government Departments,particularly that for the Environment, and includewomen in some of the senior posts. Unlike the

Departments criticised in the report, it should notlack a sense of urgency.

Pseudomonas BronchopneumoniaPseudomonas œruginosa has been described as the

nearest thing to spontaneous generation. As a ruleof thumb any moist site in the hospital environmentmay harbour this organism. It can survive and

multiply even in disinfectants and at low tempera-tures. Many people harbour this organism in smallnumbers in their fseces. Unlike Staphylococcus aureus,its mechanism of infection is ill understood. Its

appearance in burns, wounds, and the urinary tractmay lead to serious or fatal infections.1 Until quitelately, Ps. ceruginosa was a rather unusual cause ofbronchopneumonia, but a dreaded one because of itsresistance to most antibiotics. It is now suggestedthat this type of infection is increasing in bothchildren 2 and adults.3 The outcome of any infection is determined by

three factors-the virulence of the infecting organism,the resistance (local or generalised) of the host,and the number and site of inoculation of the organ-ism. A combination of these factors may be involved,with varying emphasis. Ps. œruginosa is an indifferentpathogen for pulmonary tissues, so other factorsmust be important in the genesis of pneumonia.Malignancy, leukaemia, steroids, and cytotoxic andimmunosuppressive drugs all cause a depression ofimmunity. Premature infants may be more suscept-ible because their immunological systems are im-mature. IgG is acquired from the mother by trans-placental transmission, but IgM, which is particularlyimportant in protection against gram-negative infec-tions, must be produced endogenously. Again,immunity wanes with age, so the elderly are also

susceptible. A variety of other factors, includingextensive operations and advanced renal disease, havebeen incriminated in the reduction of resistance.Patients on ventilators often have Ps. œruginosa intheir tracheostomy sputum. In many cases this seemsto have little pathological effect, but in other cases,especially if the body defences are depressed, illnessand death may ensue.

4 Outbreaks of infection havealso been traced to incubators: the humid environ-ment they provide encourages the rapid growth of thecontaminative organism, and a large inoculum will bedeposited in the lungs of a susceptible infant. Anti-

1. Lancet, 1966, i, 1139.2. Barson, A. J. Archs Dis. Childh. 1971, 46, 55.3. Pierce, A. K., Edmonson, E. B., McGee, G., Ketchersid, J.,

Loudon, R. G., Sandford, J. P. Am. Rev. resp. Dis. 1966, 94, 309.4. Tinne, J. E., Gordon, A. M., Bain, W. H., Mackey, W. A. Br. med.

J. 1967, iv, 313.

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.