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and, as Ransohoff 3 points out, recent work indicates that,with profound hypothermia and complete cardiac arrest,a surgeon may be enabled to work in a totally avascularbrain for up to an hour-which suggests that reconstruc-tive surgery on the cerebral arterial tree may become

practicable in the foreseeable future. The next decade islikely to bring as many advances in the management ofthis condition as has the last.

THE BIRDS

Cryptococcus neoformans is a yeast-like fungus whichoccasionally infects the human central nervous system:until the introduction of amphotericin B the outlook forthe patient was poor. Three recent cases in New York cityhave almost literally put the cat among the pigeons. Thefungus has been known for many years to be presentsometimes on the skin and tonsils of healthy men andin various domestic animals. Latterly, Emmons 4 5 hasshown that it may be found in soil from many sites andthat the fungus is especially abundant in the nests ofpigeons. This evidence was enough for the city healthdepartment, which declared that it was about to wagewar on the city’s five million pigeons and to give noquarter.

6

The practical difficulties in exterminating pigeons areconsiderable, and as a first step the city fathers proposedthat feeding the birds should be made a penal offence. Thepopular reaction was immediate and unfavourable. Fillingthe bottomless stomachs of these birds gives a lot of

pleasure to many citizens, who argued that humandiseases came from human sources, that pigeons neverhurt anyone anywhere, and that the brutal bureaucratswho were suggesting this outrage were the same men whowished to poison the population by adding fluoride to thewater. And so on.

Where the matter stands now we do not know. Twodeaths from a disease whose origin must still be no morethan a guess do not seem grounds for a massacre of theinnocents: if the city of New York wishes to lower itsalready low death-rate it could pay some attention to theautomobile, which is a killer far more easily controlledthan the pigeon. There are other good grounds, however,for reducing the pigeon population of large cities, andthese may have influenced the New York autnorities atleast as much as the danger to health. We would supposethat ornithosis is a far more real danger to health thaninfection with C. neoformans, but if the risk were seriousTrafalgar Square would be uninhabitable. The amountof guano that pigeons can deposit is beyond easy belief: 50tons was removed not long ago from the roof of the ForeignOffice. By reason of its acidity this guano damages lime-stone facings and statues. The nests block guttering anddownpipes. Many flat dwellers find amorous cooing amost disturbing din at 5 A.M.The control of pigeons was considered at a conference

of experts, and some of the suggested methods seemed tohold promise. Many devices-loud bangs, uncomfortableperching wires, stuffed or simulated birds of prey-haveproved useless after some initial success. Trapping is

merely palliative. Narcotic baiting-illegal except underlicence-is less successful with pigeons than with rooks.4. Emmons, C. W. Trans. N.Y. Acad. Sci. 1951, 14, 51.5. Emmons, C. W. Amer. J. Hyg. 1955, 62, 227.6. New York Times, Oct. 1, 1963.7. Proceedings of the First British Pest Control Conference, 1963. Industrial

Pest Control Association, 86, Strand, London, W.C.2.

Repellents, such as flaked naphtha, fail because birds havea poor sense of smell. Birdlime (in modern formulations)has been used in the U.S.A., but it is said that such

cruelty would not be tolerated here. The most successfulrepellent has proved to be a synthetic plastic compound,easily laid and with a life of several years, which is at onceyielding to the feet and tacky. We have never strolled onan acre of jelly, but evidently the birds do not like it. Theyfly off unhurt to perch on some untreated building andprovide persuasive argument to the occupier of their newlodging for applying the repellent as soon as he can. Onespeaker called it a mild form of blackmail.Some years will elapse before this repellent can be

applied to all the perches in every city plagued withpigeons, and it is interesting to speculate on the fate of thebirds when this has been done. We suspect that there ismore in the feeding of pigeons than the indignant citizensof New York will allow. Venice has fed its pigeons at thepublic expense since time immemorial, and they are nowthe city’s major blot: they foul the buildings, hide thestatues, and get under the pedestrian’s feet. One pigeonby itself is a pretty bird; a dozen on the wing give an ele-gant display; several thousand anywhere are a publicnuisance of the first order.

ANTIBACTERIAL POLICY IN OTHER LANDS

A Nobel prize-winner recently remarked that " bacteriaare licked ". In some laboratories this may seem possible; but in the clinical laboratory and the ward it seems muchless certain. New drugs and new techniques for thecontrol of infection have been developed intensively andingeniously; but, almost synchronously, old organismswith new properties have emerged to challenge theseachievements. The problem is no longer confined to thetiresome mutation of the staphylococcus: coliforms,proteus, and Pseudomonas pyocyanea, among other

organisms, are attaining prominence as major causes ofinfection and cross-infection. In so far as we are allstudents of applied biology, the evolutionary situation isfascinating; but as practitioners we have to contemplatesome action.

A useful lead comes from Australia, where the NationalHealth and Medical Research Council have published arevised edition of a special report 1 on the chemotherapyof infection. Like its predecessor, this report emphasisesthe need for cumulative clinical and bacteriologicalexperience in the treatment of infections so that " whenempirical therapy is necessary, such previous knowledgeenables the clinician to select drugs wisely ". Thecumulative experience on which this report is based is

largely that of clinicians and bacteriologists in Melbournewho have assessed critically the use (and abuse) of over130 drugs. In general the report combines flexibility withcaution and illustrates the practicability of rational, as

opposed to speculative, therapy. Except in chronic ormixed infections, combined therapy is discouraged.

In Denmark, Jensen and Kiaer 2 compare the emergenceof drug-resistant staphylococci to that of tubercle bacilliand suggest that combined therapy is essential if this isto be avoided. The analogy is interesting; but the evidenceoffered in support, even if echoed,3 is slender. Using the

1. National Health and Medical Research Council of Australia. SpecialReport Series no. 6: Chemotherapy with Antibiotics and AlliedDrugs. 2nd edition. Canberra, 1963.

2. Jensen, K. A , Kiaer, I. Ugeskr. Laeg. 1963, 125, 275.3. Jensen, K. ibid. p. 1225.

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new Danish antibiotic, fusidic acid,4 as an example, theseworkers say that staphylococcal resistance is due in the

patient, as in the test-tube, to the persistence duringtreatment of drug-resistant mutants; they claim that thisis prevented by adding penicillin, methicillin, or novo-biocin. It is of course accepted that suitable concentrationsof various drugs often exhibit additive effects or synergy invitro, but it is also known that the introduction of a seconddrug can interfere with the rapid bactericidal action of thepenicillins. Furthermore, during treatment the pyogeniccocci do not acquire resistance to the penicillins in the sameway as to fucidin. Meanwhile Eriksen and Erichsen 5

have shown that staphylococci resistant to the newer

penicillins are occurring in Denmark as in Great Britain.The origin of these strains is at present obscure; it is

perhaps time for information to be pooled, so that thiskind of development may be foreseen if not prevented.In calling for rational treatment based on epidemiologicalas well as clinical strategy, the Australian and Danishworkers are taking the first steps towards such a policy.Bacteria will never be beaten if drug resistance is acceptedpassively or is regarded as inevitable.

TAPE IN TEACHING

ARE medical teachers unwilling to make full use of themany new methods now available of making learningeasier for both teacher and taught ? At an informal con-ference on the Use of Tape in Medical Teaching held atthe College of General Practitioners last Saturday, thisproblem was discussed before an invited audience.The spoken word can have a greater impact on a student

than anything he reads: this power of the spoken word ishard to define, but teachers find themselves returning to ittime after time. Nobody would deny that everyone, be hestudent or postgraduate, must depend on reading for mostof his instruction: but interest must first be stirred so that

reading is purposeful and rewarding, not merely a feverishdevouring of pages. Interest, and a desire to know more,may be aroused by well-designed well-illustrated lecturesfollowed by discussion. If students are bored or be-

wildered, the lecturer is wasting his time: but this could bean indication for improving the lectures rather than forabolishing them.Dr. John Graves of the College of General Practitioners’

Medical Recording Service pointed out that a recordedtalk could be carefully designed for its purpose, polished,and illustrated with good diagrams and photographs. Itcould be played over and over again, and altered to keepit up to date. This could free the lecturer for the muchmore important tasks of discussion with students andchecking individual progress. It could also carry ideas to

postgraduates in every corner of the world-to East Africahardly less quickly than to East Ham. The RecordingService sent thousands of tapes a year to doctors in everybranch of medicine all over the world. Should not theschools and universities feel it their responsibility to

provide material of this kind for their graduates, to keepthem in touch with modern thought and practice; to givepoint to their reading; and to promote that discussion andargument that develops the inquiring mind ?Mr. Harry Asher of Birmingham University spoke of

his use of taped lectures for individual teaching in physi-ology, students playing back at their own pace, stopping4. See Porter, I. A., Wilson, J. S. P. Lancet, Sept. 28, 1963, p. 658

Dodson, B. ibid. p. 659.5. Eriksen, K. R., Erichsen, I. Ugeskr. Laeg. 1963, 125, 1234.

to make notes, and repeating the talk until they felt theyhad understood it. Why, he asked, were other teachershostile to this idea ? It was not pleasant to listen to oneselfspeaking and discover one’s errors and mannerisms, butthis salutary experience certainly led to better performance,and students were very much in favour of the method.The load on the teacher was lightened, and-most impor-tant-he became aware of the weak spots in his teachingtechnique.A general practitioner, Dr. T. H. H. Green of Wallasey,

said that he regularly used the college’s tapes for smallgroup discussion. The group must be small, he said-many doctors were unwilling to step forward at a bigmeeting. A high standard of inquiry and argument wasreached, and a feeling of sharing in common problems.Consultants often joined the group for discussion, andthis encouraged better relationships between hospital andgeneral practice. Such groups (of which more than ahundred are now known to the college) were a powerfulmethod of reaching out to the uncommitted 90%who never attended courses, giving them a taste for

learning.Another use of recorded sound is to illustrate and

amplify traditional methods of teaching. Prof. J. K.

Russell, of Newcastle, demonstrated recordings of his-tories given by gynxcological patients. These could bediscussed at length with undergraduates without upset-ting the patient. He kept a library of short recordings andphotographs of

"

typical " patients, and used them to

illustrate his lectures. Students, he found, remembereda point better if it had been personalised in this way. Twospeakers from Liverpool, Dr. P. Pinkerton and Dr. H. G.Farquhar, demonstrated teaching tapes of interviews withpatients and of heart and chest sounds. Tapes did notreplace clinical teaching: they enhanced its value; becausethey could be repeatedly replayed they helped to developa student’s power of critical listening.During the discussion, clinical and other teachers agreed

that there was a traditional hostility to audiovisualmethods that would have to be overcome. Illustrationsand recordings could do much to improve teaching, pro-vided that they were of very high standard. An entirelydifferent style was required for a recorded talk as opposedto a formal lecture. More should be done to evaluate theeffectiveness of methods of teaching, and to keep post-graduates interested in learning. Dr. E. C. O. Jewesburyplayed an extract, demonstrating the effect of ’ Tensilon ’on the speech of a patient with myasthenia gravis, froma tape on speech disorders that he had made for thecollege. This was a striking demonstration of the value ofthis kind of recording, and there should be more collec-tions of illustrative recordings and talks for loan to

teachers and students. Summing up, the chairman,Dr. Ronald Mac Keith, said that tape had two differentuses-to improve individual learning and to encouragegroup learning.There is a reawakening of interest in techniques of

medical teaching. Money and attention are being lavishedon new postgraduate and other teaching centres. Darewe hope that they will encourage and develop the use oftape and similar media ? Or will they be new bottlescontaining " the mixture as before " ?

Dr. RICHARD SCOTT has been appointed the first holder ofthe James Mackenzie chair of general practice in the Universityof Edinburgh.