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The explanation of the steatorrhoea seems to lie not somuch in damage to the intestinal mucosa as in therapid passage of the intestinal contents and consequentfailure to absorb the vitamins and other substancesnecessary for the complete metabolism of fats.

It seems reasonable to draw a parallel between thetwo syndromes of sprue and pellagra, in both of whichwe can recognise a primary and a secondary form, theprimary form arising from lack of vitamins in the diet,the other being secondary to intestinal infection. Thisview is supported by the experience reported in our issueof Oct. 28 (p. 560) by Howat-stomatitis and steator-rhcea were an increasingly common sequel to dysenterynot only among prisoners-of-war but among British

troops on a "balanced and well-controlled diet." Thehalf-starved British prisoners whom Bloom (p. 558)treated against heavy odds in Italy presented the

symptoms and signs of multiple vitamin deficienciesand famine oedema, and all were reported as havingEntamaeba . histolytica in their stools, with a multitudeof other organisms. Their large pultaceous stools wereof the frothy type, as in tropical sprue. Axis prisonerscaptured at Alamein included men whom the enemyhad been compelled to keep in the battle zone thoughthey were suffering from untreated, or partially treated,dysenteries as well as privation ; it is said that manyof these showed signs of vitamin-B2 deficiency, and somehad steatorrhoea. This observation recalls that ofEnright 3 among German and Austrian prisoners cap-

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tured in the Palestine campaign of 1918. These menhad " lived on the fat of the land " before capture, andhad received what was thought to be a fully generousdiet in the camps afterwards ; yet Enright could report65 cases of pellagra in one hospital, with offensive, copiousand sometimes porridgy stools. It was notable thatonly 3 of the 65 men had no previous history of diarrhoeaor dysentery, and E. histolytica or dysentery bacilliwere the usual finding in their stools. Thus it is not

easy to apportion the blame for sprue-like sequeloebetween infection and dietary deficiency. A further

complication is the suggestion, made by Howat, thatsulphaguanidine may favour the production of vitamin-Bcomplex deficiencies by inhibiting the symbiotic organ-isms in the bowel which synthesise these growth factorsior tnemseiyes anu incidentally zor ineirhost. This is a suggestion worth pursuing,though there is as yet no convincingevidence that postdysenteric " spruesyndrome" is more common with sulphon-amide treatment than in patients treatedby the older methods. It may be wise toheed the advice of Najjar and Holt 4 andof Ellinger and his colleagues 5 to attendto the vitamin-B status of the patientwhen employing " chemotherapy withinthe bowel." .

The behaviour of a man’s intestineis largely a reflexion of his mental attitude,so excitable types are likely to be seriouslyaffected by low-grade bowel infections,and to develop that intestinal hurry whichmay predispose to pellagra, sprue, coeliacdisease and even idiopathic steatorrhoeain adult life. Whatever may be the

changes in intestinal physiology in thesediseases they may be partially reversed bygiving a high protein diet and vitamin B2;but relapse remains a distinctive feature ofthe whole group. Recrudescence of proto-

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zoal disease, or mild intercurrent infectionof a much buffeted bowel, may be

3. Enright, J. I. Lancet, 1920, i, 998.4. Najjar, V.A., Holt, L. E., jun. J. Amer, med. Ass.

1943, 123, 683.5. Ellinger, P., Coulson, R. A., Benesch, R. Nature,

Lond. 1944, 154, 270.

enough to upset the precarious balance of intake andabsorption. While we await the explanation of thesedisorders we must bear them in mind when treating thedysenteries, acute or chronic, remembering that sulpha-guanidine may cut off the patient’s supplies of home-grown vitamin-B2 complex and that it is sometimes asimportant to quieten a man’s mind as his bowel.

GUY’S PLANS

WHEN we think of the hospital beds destroyed in thiswar, of their shortage before it, and of their additionaluse after it, we must conclude that the next half-centurywill be one of great hospital construction. Guy’s seemsto be the first of the London teaching hospitals to publisha postwar plan, though the governors have wiselydecided that it is provisional only. To make provisionalplans stimulates thought without fixing ideas. Thefirst datum that must be established before planning anysuch institution is the number of beds based on the needsof the population in relation to all other hospitals in thevicinity. The great voluntary hospitals have alwaysattracted patients from outside the county area. Thesepatients are likely to become relatively fewer as pro-vincial centres become self-supporting, considering thestandard of work now being done in hospitals that havearisen since the passing of the Local Government Act of1929. But the main supply of clients to any hospitalmust be drawn from families who live near by. It maybe easier to see how these two classes of potentialclients can best be served in London when the survey byDr. A. M. H. Gray and Dr. Andrew Topping is published ;

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it is said to be in the printer’s hands. Next there aretheir exits and their entrances. We think of a hospitalas a place where patients are. We seldom think of howthey get in and out, or of all that serve them directlyand indirectly, and come to inquire of or to visit them,not to mention supplies perishable and imperishable,consumable and permanent, medical, nutritional, mech-anical and constructional. The ideal would be forthese after entry to have different routes to and fromtheir loading and unloading sites, but some vehicleshave to remain stationary, sometimes for long periods,between loading, unloading and reloading ; hence theneed for adequate parking-places away from avenues of

Tentative plan for reouiiding (juy’s Hospital, including a central administration block; a surgicalblock for 600 beds ; a student’s college far 150 persons ; and a dental blo.ck for 400 students.Existing buildings, with the exception of Hunt’s House, are shaded: (I) Hunt’s House for medicalpatients, &c. (2) Nuffield House for paying patients. (3) Medical school. (4) and (6) Nurses’home. (5) York psychiatric clinic. (7) Laundry. (8) and (9) Staff hostels. (10) Massage andelectrical departments. (II) Mortuary. (12) Works department.

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movement. Then this internal circulation needs to beharmonised with movement outside. In all great citiesthere will be planning of movement, and the hospitalgates must not be placed so that to enter them everyvehicle must cut across the traffic of a two-way, street,or must leave them contrary to the current of a one-waystreet. Then there is arrival by air. If a fightingplane can land on an aircraft-carrier, an ambulanceplane can land on the roof of a modern hospital, andmust do so. Next is the problem of recreation. Notthat of the convalescent but that which leads to con-valescence, or occupies the mind of those awaitingoperation, undergoing investigation, or recovering fromeither. This should include floor space for dancingand a cinema-show, side-rooms or recesses therefromwhere cronies can gossip, as well as a canteen where amodest glass of beer should be obtainable, if the con-sciences of the committee approve. Such a hall ofrecreation should be common to patients and all workers

_ in the hospital, including nurses and doctors, and, wherea medical school is attached, students of both sexes.

.

When this is done we need to consider the buildings notin terms of wards but of ward-suites, and these must beconstructed not for the idiosyncrasies of the day but forall the time that the hospital will stand. This is not

likely to be less than 50 years and may be 200. Whenat the end of these years the ward-suites are still func-tioning without undue conflict the stones of that

hospital may be said to have been well and truly laid.

A MOULD INHIBITING TUBERCLE BACILLI

THE symbiosis of the tubercle bacillus has alwaysbeen rather a dark corner of the bacteriological field.One wants to know why the tubercle bacillus often

disappears from discharging sinuses when other organ-isms gain access ; how and why the chronic suppurativelung lesion will sometimes light up an old tuberculousfocus ; why the secondary infection of a cavity inhibitsthe tubercle bacillus ; and why the tubercle bacilluswill occasionally appear at the site of a suppuratingwound-questions which seem to have apparentlycontradictory answers. Penicillin has brought the issueto the front again. Miller and Rekate have studiedthe inhibition of the growth of a strain of Mycobacteriumtuberculosis by a green mould of the penicillium groupaccidentally grown on a subculture of tubercle bacillus °

stored in the ice-box. Subcultures of this mould onother cultures of tubercle bacilli showed rapid andluxuriant growth at room temperature but no growthat 37° C. On cultures of tubercle bacilli the mouldgrew faster and sporulated earlier than it did on othersterile media employed. The mould also, grew on

suspensions of tubercle bacilli in saline solution alone.In the experiments recorded suspensions of rapidlygrowing human strains of tubercle bacilli were madein saline solutions and added to suspensions of mould,the pH of the latter varying from 6-5 to 7-8. Themixed suspensions were then allowed to stand for24-48 hours at room temperature. ’An attempt wassubsequently made to recover the tubercle bacillus byculture, but, although acid-fast bacilli were still presentin smears in 12 out of 13 instances, the attempt failed.Guineapig inoculation tests were not so definite butsuggested that some inhibition of growth had takenplace. In a second series of experiments the mouldwas grown at room temperature on cultures of tuberclebacilli, after which the bacilli failed to grow on sub-culture though control cultures under the same con-ditions grew rapidly. The mould,grew well on tuber-

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culin in dilutions as high as 1 : 10,000, and the dilutionsof tuberculin thereafter failed to give positive skinreactions in tuberculous guineapigs. Suspensions ofthe mould inactivated 1 : 100 tuberculin in 2 hours, and

1. Miller, D. K., Rekate, A. C. Science, 1944, 100, 172.

the supernatant fluid obtained after centrifugation of amould suspension also inactivated 1 : 100 tuberculin,-but this did not occur when the suspension was passedthrough a Seitz filter. Fluid media, however, on whichmould had been grown for 8-15 days, had no effect ontubercle bacilli or on tuberculin, while Staphylococcusaureus grew on solid media on which the mould had been

grown and removed. It is therefore assumed that the sub-stance produced in this mould is not similar to penicillin.

NURSING DEMONSTRATION TEAMS

THE hospitals that train nurses are scattered up anddown the country. Many of them are almost isolated,and most of them are almost autonomous. When weadd that they are all overworked it will be evident whyinnovations in nursing technique sometimes take a longtime to pass into the practice of the wards.

Difficulty of transport and shortage of staff preventward sisters from attending the refresher courses thatmight bring their methods up to date ; and at first sightit may seem that nothing can be done about this tilltimes change. But when a mountain cannot come toMahomet, there is an obvious alternative. Could notdemonstration teams hold practical refresher courses inthe hospitals themselves ?, A crack team of sistersmight staff an entire ward for, say, a fortnight, anddemonstrate the latest nursing techniques in one or

more of the kinds of case treated in the hospital-e.g.,fractures chest, cases, spinal or head injuries, maxillo.facial injuries, or tropical diseases. In this way infor-niation would spread from the centres that havespecialised in particular work, and spread far faster thanit does today. The visit of the nursing team might bemade the occasion of a kind of nursing conference, withsocial gatherings in the evening where nursing problemscould be discussed over coffee and cakes, medical filmsmight be shown, debates and lectures held, and a danceor two fitted in. The refresher course would be offered

primarily to ward sisters who might take it in turns towork in the demonstration ward with the team; but a fewdemonstrations of the simpler techniques might also bearranged for student nurses, with a view to encouragingthem and arousing keenness. The student nurses as wellas the sisters would join in at the social gatherings.

Senior nurses fear that there might be some prejudicein the hospitals against such an influx of strangers ;but this should not develop if the course is properlypresented to them. Nurses as a whole enjoy refreshercourses, and though a course at home would lack thenovelty and the change from the familiar round whichare part of the charm of a course in another centre, thevisit of the team would give them the chance to modifytheir accustomed routine, and incidentally to exercisetheir well-known gift for hospitality.Perhaps the Ministry of Health would consider the

formation, training and employment of such teams.

WE regret to record the death on Nov. 4 of SirGEORGE CHRYSTAL, late Permanent Secretary to theMinistry of Health. Eldest son of the famous Edinburghmathematician, he entered the Civil Service at theAdmiralty in 1904. As secretary to the Ministry ofPensions in 1919, he took a special interest in themedical work of the department, and he moved to theMinistry of Health in 1935. There, with the late SirJohn Hebb, he carried the greater part of the burden ofsetting up the Emergency Medical Service, and of manyother preparations for war such as the heavy work ofthe supply committees. He was a man of friendlydisposition, always approachable and helpful, and whenpoor health led him to retire in 1940 he left the Ministrywith the sincere regrets of his colleagues.THE death is announced in Paris of Dr. ALEXIS

CARREL at the age of 71. Dr. Carrel was a Nobellaureate and an emeritus member of the RockefellerInstitute for Medical Research. -