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MEDIA URNAL

is often comparatively high. In such cases particular importance is attached to the need for thorough oestrogen therapy, since, if the growth can be brought under control by this means, the subsequent chances of survival appear to be improved. The choice of oestrogen merits careful consideration to ensure that a fully active preparation is employed, and from tracer experiments Fergusson' has so far been unable to confirm that the recently introduced phosphorylated compounds are superior in their effect except by virtue of the large dosages which can be given. Supplementary methods of endocrine control by adrenalectomy and pituitary inactivation, which are sometimes applied in relapsing cases, may also modify the later course of the disease. The likelihood of their success again appears to be related mainly to the early therapeutic response rather than to any specific pathological feature. This suggests that in prostatic cancer the outlook is determined to a greater extent by endocrine sensitivity than by histological grading or any other factor which can at present be measured in the laboratory. It is to be hoped that this new conception of growth activity will stimulate the introduction of some method of initial biological assay which will ultimately serve as a reliable guide to both the choice of treatment and the prognosis.

UMBILICAL SEPSIS AND ITS CONTROL

When the umbilical cord is cut and tied at delivery a raw area is left the best treatment for which is not yet settled. This stump of tissue separates from the infant by a process of gangrene which may be either wet or dry and, more important, may be sterile or infected. In maternity units attention has recently been focused on the umbilicus as a source of infection, and methods of dealing with the cord during the puerperium have been under review. A recent paper from the U.S.A. by J. P. Fairchild and colleagues1 reports not only that 80% of about a thousand infants had Staphylococcus aureus at this site but also that many infants carried haemolytic streptococci. Whether any of these were Lancefield Group A is not stated. This high rate of bacteriological, as distinct from clinical, infection may have been encouraged by the policy of allowing the cord to separate without the application of any form of antiseptic or dressing. When the "no dressing" technique is adopted, a
IFairchild, J. P., Graber, C. D., Vogel, E. H., jun., and Ingersoll, R. L., J. Pediat., 1958, 53, 538. 2 Boissard, J. M., and Eton, B., Brit. med. J., 1956, 2, 574. sKwant.s, W., and James, J. R. E., ibid., 1956, 2, 576. 4Colebrook, L., ibid., 1956, 2, 711. Jellard, J., ibid., 1957. 1, 925. Proc. roy. Soc. Med., 1957, 50, 705. 7 Colebrook, L., J. Obstet. Gynaec. Brit. Emp., 1936, 43, 691.

variety of organisms can be isolated from the umbilicus and tend to remain on the cord until it separates, though generally not causing a true inflammatory reaction. J. M. Boissard and B. Eton2 in Cambridge and W. Kwantes and J. R. E. James3 at Carmarthen have found the infant's umbilicus to harbour Group A haemolytic streptococci during outbreaks of puerperal sepsis, but it is interesting that in their cases as well as in those of Fairchild and colleagues the babies remained well. In fact, while there are many reports of trivial infections in these babies, it is rare for serious illness to result from infection of the umbilicus. Possibly maternity units sometimes do not hear of babies who are discharged well but later develop serious infection by way of the umbilical stump, for they may be admitted to other hospitals. Even so, the low incidence of infection in the presence of a high rate of carriage of organisms is striking, and there must be other factors such as trauma or debility which determine the occasional case of true umbilical sepsis. There are two separate problems-to prevent the occasional case of true umbilical sepsis, and to prevent the spread of organisms within the hospital by their carriage on the umbilical stump. It follows that the treatment of the cord after birth has two functions-to protect the baby from infection entering by way of the umbilicus, and to help break the cycle of carriers of hospital strains of organisms, in particular Staph. aureus and sometimes Group A haemolytic streptococci. Several years ago the routine was to apply a binder and pad, with or without a drying powder, which might contain an antiseptic. The disadvantages of this method were thought to be the irritation of the baby's skin, the harbouring of organisms by the usually wet binder, the extra work for nursing staff, and the additional handling of the baby. Opinion consequently swung against the use of any antiseptic or dressing on the cord, but it is since the latter technique has been adopted that persistent carriage of pathogenic organisms at this site has been observed. Owing to reports of this carrier state and consequent fears of true umbilical sepsis, the trend is now towards applying antibacterial agents to prevent the colonization by organisms of this open surface. There is no general agreement yet on which substances should be used for the purpose. Because of the danger of encouraging penicillin-resistant organisms, few people would now agree with Colebrook's4 suggestion for applying a penicillin cream, effective though this would be against haemolytic streptococci. Is fact, the problem of

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UMBILICAL SEPSIS AND ITS CONTROL

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antibiotic-resistant strains of staphylococci is such that no systemically used antibiotic can be considered suitable. Ideally, an agent is required which will be an efficient antiseptic, be non-irritant to the babies' skin, will dry the cord, and assist separation; further, it should not stain the linen or have an unpleasant colour or smell. In addition, its use must not stimulate resistance to agents likely to be used in systemic treatment. The combination of crystal violet and brilliant green known as Bonney's Blue is most effective as an antiseptic, but cords so treated may tend to stay on longer than usual and the colour is not very acceptable to most mothers. J. Jellard5 has described good results with " triple dye," but this suffers from the same disadvantages. Chlorhexidine used as a 1% solution in spirit is most effective, does not irritate the skin, and, being nearly colourless, is pleasant to use. The stump so treated can then be protected with a strip of sterile gauze. As was shown at Queen Charlotte's Maternity Hospital,6 while various organisms can be isolated from the umbilicus on different occasions when such a routine is instituted, they do not maintain themselves there. There seems to be much to be said, then, for applying antiseptic to the cord and not leaving it unprotected ; but equally it is a mistake to regard the umbilicus as the primary source of infection in babies. Babies become infected with staphylococci from all their surroundings, and control of this organism can be achieved only by measures directed at all persons and things coming into contact with the infant. While the umbilicus may act as a transient carrier of streptococci, it cannot be regarded as the primary source of infection. Outbreaks of streptococcal sepsis will be prevented only by continued adherence to the careful technique for control of this infection originally described by Colebrook.7 The care of the umbilicus must remain only one of these.

VISCERAL REPLACEMENT The replacement of a diseased organ by an efficient substitute has been the subject of experimentformany years. Inert materials such as metal orsyntheticplastic
have been used with varying degrees of success in orthopaedic surgery; more recently, fabric grafts of woven plastic material have been inserted to bridge large arterial defects. In the latter case the graft is invaded by fibroblasts and the foreign material is incorporated into the new living vascular wall. The visceral cavities are lined with cells capable of withstanding fluids of unphysiological composition and of preventing the entry of micro-organisms into

the body; hence it is necessary that any prosthesis for replacing part of the gut should have an epithelial lining. Tubes lined by split-skin grafts are seldom satisfactory, and in practice the only suitable graft is a segment from another part of the alimentary tract. An isolated loop implanted into a new site may act merely as a conduit, but more usually it is needed in addition as a reservoir. Since an isolated segment of a viscus is not viable as a free graft, its blood supply must remain intact wherever it may be transplanted. It must therefore either be situated close to the defective organ which it is to replace or have a long, mobile vascular pedicle. Anastomosis of mesenteric blood vessels to those of somatic tissues near at hand-for instance, jejunal to internal mammary-has occasionally been successful, but the method is not generally suitable because of the high frequency of thrombosis. A reliable method of joining small vessels would be of great value in this field of surgery. Interest has been focused mainly on the replacement or modification of three visceraoesophagus, stomach, and bladder. The idea is not a recent one, for von Mikulicz is said' to have enlarged a contracted bladder with an isolated loop of ileum in 1898 and G. Kelling' used the ascending colon for oesophagoplasty in 1911. It is only in the last few years, however, that advances in surgical technique, chemotherapy, anaesthesia, and transfusion have made such procedures reasonably safe. The problem of providing a new reservoir for urine after cystectomy may be solved in several ways. The standard method of ureteric transplantation into the intact colon is followed too often by recurrent pyelonephritis. This complication may be avoided if the ureters are anastomosed to a loop of bowel which has been isolated and is no longer a faecal conduit. For instance, the colon may be divided at the rectosigmoid junction, the lower part closed, and the rectal ampulla used as a new bladder.3 Urinary continence is maintained by the rectal sphincters; an inguinal colostomy may be created for evacuation of faeces or alternatively the proximal end of the recto-sigmoid may be drawn down anterior to the rectum, passing through the anal sphincters, so that control of urine and faeces is established by the same group of muscles.4 Another method is to transplant the ureters into an isolated loop of ileum; one end may be brought to the skin to allow discharge of urine6
1 Tasker, J. H., Brit. J. Urol., 1953, 25, 349. 2 Kelling, 0., Zbl. ChIr., 1911, 38, 1209. 3 Pyrah, L. N., J. Urol. (Baltimore), 1957, 78, 683. 4 Lowsley, 0. S., and Johnson, T. H., ibid., 1955, 73, 83. Bricker, E. M., Surg. Clin. N. Amer., 1950, 30, 1511. Couvelaire, R., J. Urol. med. chlr., 1951, 57, 408. Scanlon, E. F., and Staloy, C. J., Sur. Gynec. Obstet., 1958, 107, 99. Henloy, F. A., Ann. toy. Coil. Surg. Engl., 1953, 13, 141. * Moronny, J., L4ancet, 1951, 1, 993.