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INFANTILE GASTROENTERITIS
1339 INFANTILE GASTROENTERITIS
patient is saved from future complications from the gallstones, will but the incidence of a post-cholecystectomy syndrome be something like 30%. "
SiR,-Dr. Brown and Dr. Bailey (Dec. 14) report that there are many unjustifiable admissions to gastroenteritis I entirely agree and wish to offer a possible units.
explanation. It is insufficiently realised
are many other in as well as infancy vomiting infective gastroenteritis and that gastroenteritis is unlikely to be the diagnosis unless anorexia and a certain amount of toxaemia are also present. This misconception in the unfortunate is particularly underfeeding svndrome.1-3 It is the more than usually vigorous babies who are most prone to be underfed, since an average diet is unlikely to be sufficient for them, and if their hunger is aggravated by a period of starvation, the usual treatment for gastroenteritis, their reaction may be such that the parents give up the struggle in desperation. My "
causes
that there
of diarrhoea and
impression is that many " gastroenteritis admissions, especially infants under 3 months old, fall into this category.
Although many different factors have to be considered in each case, and even then the diagnosis may remain conjectural, I would suggest the following general rule. If an infant with diarrhoea and vomiting refuses his feeds, but is thirsty, infective gastroenteritis is likely to be the diagnosis and a period of starvation is indicated ; but if he is hungry, feeding him until his appetite is satisfied, with either half-cream or full-cream milk as thought fit, is unlikely to do harm and often effects a cure. Ruchill Hospital, H. G. EASTON. Glasgow.
COMBINED BARIUM MEAL AND CHOLECYSTOGRAPHY
SIR,-The article by Professor Johnstone and Dr. Sumerling (Nov. 30) interested me particularly on account of their statement that 48% of patients with a normal cholecystogram were found to have disease of the upper alimentary tract. While appreciating that they are concerned primarily with evaluating the technique of combined barium meal and cholecystography, I feel that their observations would be of particular value to surgeons if
they could separate the group of "pathological gallbladders-i.e., non-functioning, or functioning with demonstrable gallstones " into its two components. Clinically, the functioning gallbladder with gallstones a problem, and a particularly difficult one, which resembles that of the normal gallbladder more closely than that of the pathological gallbladder. Removal of a normal gallbladder is mistaken surgery, for not only will it fail to relieve symptoms, but also it is followed in a high proportion of cases-estimated at 30% by Ogilvie 4-by symptoms attributable to the operation and for which, for lack of precise knowledge of their nature, the term choledochodyskinesia may be accepted. Unfortunately the removal of a functioning gallbladder which contains gallstones is followed by similar symptoms in about the same proportion of cases. This is not surprising when one considers that such gallbladders at laparotomy and on microscopical examination often show no pathological abnormality. Their classification with pathological gallbladders on the basis of the stones which they contain is therefore one which clinically causes only confusion. It is my practice always to ask for a barium meal in patients referred to me with a functioning gallbladder containing gallstones, and in many cases this has revealed a peptic ulcer, and presents
"
It would therefore be especially interesting if Professor Johnstone and Dr. Sumerling could say in what proportion of their cases of functioning gallbladders with gallstones they found lesions in the upper gastrointestinal tract and what these lesions were. Edgware General Hospital,
FRANK FORTY.
Middlesex.
PNEUMOCONIOTIC NEUROSIS
SiR,-Dr. Dunner and Dr. Hardy (Nov. 23) think it
justifiable to regard bronchitis and emphysema as a direct result of inhaling irritant dust. They are right, but as Dr. Holt (Dec. 14) points out, there are other aetiological factors, and it is impossible to separate one from the other. And, although the incidence of bronchitis and emphysema is high in miners, this has not been found acceptable as grounds for awarding benefit by various committees which have reviewed the problem ; one wonders why, the more so as tuberculosis, which also has other aetiological factors, is accepted as grounds for 100% compensation when found in association with pneumoconiosis. Furthermore, it is clear that emphysema of considerable degree, focal and otherwise, may be present without radiological change ; and in another occupational disease due to dust-byssinosis-radiological change is not considered essential.
Argument along these lines can continue indefinitely ; pneumoconiosis there seems to be source for endless argument. What is required is a sensible, workable solution, and Dr. Gilson and his fellow correspondents (Dec. 7) have made two useful suggestions which should be further explored. I much prefer their second alternative-that of making provision under the National Health Insurance Scheme for adequate benefits for the disabled, irrespective of how the disablement has been caused. If the political difficulties were out of the way-and they should not be over-emphasised-this can be seen as largely a matter of administrative arrangement with an appropriate adjustment of contributions by employer and employee. On the subject of pneumoconiosis itself it would seem desirable to set up a committee-which must be fully independent -to review the position in the light of present medical knowledge and to re-examine the legislative side. This problem has been in the past and still is too vexatious, absorbing time and mental energy which could The be much better applied in the preventive field. settling of the issue within the broad framework suggested by Dr. Gilson and his colleagues would confer a sense of with
freedom and relief to all concerned. Clare Hall Hospital, South Mimms, Barnet.
NORMAN MACDONALD.
CONTROL OF HYPERPYREXIA IN CHOLERA
SiR,-An apparently paradoxical feature of the cholera syndrome is pyrexia, which is evidenced even in the early stages by a high rectal temperature and is in striking contrast to the great collapse and shock with cold clammy extremities and subnormal axillary temperature.
hiatus hernia, which may be the cause of the a few occasions I have at laparotomy found evidence of peptic ulcer which the barium meal had failed to reveal. I think it is important to know that cholecystectomy in such cases will relieve only such of the patients’ symptoms as are due to gallstone colic-and that if there has been no colic the most that can be confidently claimed is that the
The pyrexia may be observed even before the administration of intravenous infusions. Rogers 12 recorded a high temperature in cholera patients who had had no intravenous saline. Of his European patients who had no saline solution about 77% were febrile. After an infusion of saline every patient with. cholera becomes feverish, usually with chill and rigor.3 The necessity of taking a correct rectal temperature before the infusion is If saline infusions are given to a patient now well recognised. whose rectal temperature is more than 101°F, there is a great risk of fatal hyperpyrexial reactions ; but if no infusion is given, the patient will probably die of irreversible shock.
1. Wood, B. S. B. Lancet, 1952, i, 28. 2. Wickes, I. G. Brit. med. J. 1952, ii, 1178. 3. Illingworth, R. S. The Normal Child ; p. 74. London, 1953. 4. Ogilvie, H. Ann. R. Coll. Surg. Engl. 1957, 21, 319.
1. Rogers, L. Cholera and its Treatment. London, 1913. Bowel Diseases in the Tropics. 2. Rogers, L. London, 1921. 3. Chatterjee, H. N., Chatterjee, K. K., Saha, R. K., Banerjee, R., Basu, D. K., Gupta, J. C., Ghosh, H. Antiseptic, 1955, 52, 85.
sometimes
a
symptoms. On
patient is saved from future complications from the gallstones, will but the incidence of a post-cholecystectomy syndrome be something like 30%. "
SiR,-Dr. Brown and Dr. Bailey (Dec. 14) report that there are many unjustifiable admissions to gastroenteritis I entirely agree and wish to offer a possible units.
explanation. It is insufficiently realised
are many other in as well as infancy vomiting infective gastroenteritis and that gastroenteritis is unlikely to be the diagnosis unless anorexia and a certain amount of toxaemia are also present. This misconception in the unfortunate is particularly underfeeding svndrome.1-3 It is the more than usually vigorous babies who are most prone to be underfed, since an average diet is unlikely to be sufficient for them, and if their hunger is aggravated by a period of starvation, the usual treatment for gastroenteritis, their reaction may be such that the parents give up the struggle in desperation. My "
causes
that there
of diarrhoea and
impression is that many " gastroenteritis admissions, especially infants under 3 months old, fall into this category.
Although many different factors have to be considered in each case, and even then the diagnosis may remain conjectural, I would suggest the following general rule. If an infant with diarrhoea and vomiting refuses his feeds, but is thirsty, infective gastroenteritis is likely to be the diagnosis and a period of starvation is indicated ; but if he is hungry, feeding him until his appetite is satisfied, with either half-cream or full-cream milk as thought fit, is unlikely to do harm and often effects a cure. Ruchill Hospital, H. G. EASTON. Glasgow.
COMBINED BARIUM MEAL AND CHOLECYSTOGRAPHY
SIR,-The article by Professor Johnstone and Dr. Sumerling (Nov. 30) interested me particularly on account of their statement that 48% of patients with a normal cholecystogram were found to have disease of the upper alimentary tract. While appreciating that they are concerned primarily with evaluating the technique of combined barium meal and cholecystography, I feel that their observations would be of particular value to surgeons if
they could separate the group of "pathological gallbladders-i.e., non-functioning, or functioning with demonstrable gallstones " into its two components. Clinically, the functioning gallbladder with gallstones a problem, and a particularly difficult one, which resembles that of the normal gallbladder more closely than that of the pathological gallbladder. Removal of a normal gallbladder is mistaken surgery, for not only will it fail to relieve symptoms, but also it is followed in a high proportion of cases-estimated at 30% by Ogilvie 4-by symptoms attributable to the operation and for which, for lack of precise knowledge of their nature, the term choledochodyskinesia may be accepted. Unfortunately the removal of a functioning gallbladder which contains gallstones is followed by similar symptoms in about the same proportion of cases. This is not surprising when one considers that such gallbladders at laparotomy and on microscopical examination often show no pathological abnormality. Their classification with pathological gallbladders on the basis of the stones which they contain is therefore one which clinically causes only confusion. It is my practice always to ask for a barium meal in patients referred to me with a functioning gallbladder containing gallstones, and in many cases this has revealed a peptic ulcer, and presents
"
It would therefore be especially interesting if Professor Johnstone and Dr. Sumerling could say in what proportion of their cases of functioning gallbladders with gallstones they found lesions in the upper gastrointestinal tract and what these lesions were. Edgware General Hospital,
FRANK FORTY.
Middlesex.
PNEUMOCONIOTIC NEUROSIS
SiR,-Dr. Dunner and Dr. Hardy (Nov. 23) think it
justifiable to regard bronchitis and emphysema as a direct result of inhaling irritant dust. They are right, but as Dr. Holt (Dec. 14) points out, there are other aetiological factors, and it is impossible to separate one from the other. And, although the incidence of bronchitis and emphysema is high in miners, this has not been found acceptable as grounds for awarding benefit by various committees which have reviewed the problem ; one wonders why, the more so as tuberculosis, which also has other aetiological factors, is accepted as grounds for 100% compensation when found in association with pneumoconiosis. Furthermore, it is clear that emphysema of considerable degree, focal and otherwise, may be present without radiological change ; and in another occupational disease due to dust-byssinosis-radiological change is not considered essential.
Argument along these lines can continue indefinitely ; pneumoconiosis there seems to be source for endless argument. What is required is a sensible, workable solution, and Dr. Gilson and his fellow correspondents (Dec. 7) have made two useful suggestions which should be further explored. I much prefer their second alternative-that of making provision under the National Health Insurance Scheme for adequate benefits for the disabled, irrespective of how the disablement has been caused. If the political difficulties were out of the way-and they should not be over-emphasised-this can be seen as largely a matter of administrative arrangement with an appropriate adjustment of contributions by employer and employee. On the subject of pneumoconiosis itself it would seem desirable to set up a committee-which must be fully independent -to review the position in the light of present medical knowledge and to re-examine the legislative side. This problem has been in the past and still is too vexatious, absorbing time and mental energy which could The be much better applied in the preventive field. settling of the issue within the broad framework suggested by Dr. Gilson and his colleagues would confer a sense of with
freedom and relief to all concerned. Clare Hall Hospital, South Mimms, Barnet.
NORMAN MACDONALD.
CONTROL OF HYPERPYREXIA IN CHOLERA
SiR,-An apparently paradoxical feature of the cholera syndrome is pyrexia, which is evidenced even in the early stages by a high rectal temperature and is in striking contrast to the great collapse and shock with cold clammy extremities and subnormal axillary temperature.
hiatus hernia, which may be the cause of the a few occasions I have at laparotomy found evidence of peptic ulcer which the barium meal had failed to reveal. I think it is important to know that cholecystectomy in such cases will relieve only such of the patients’ symptoms as are due to gallstone colic-and that if there has been no colic the most that can be confidently claimed is that the
The pyrexia may be observed even before the administration of intravenous infusions. Rogers 12 recorded a high temperature in cholera patients who had had no intravenous saline. Of his European patients who had no saline solution about 77% were febrile. After an infusion of saline every patient with. cholera becomes feverish, usually with chill and rigor.3 The necessity of taking a correct rectal temperature before the infusion is If saline infusions are given to a patient now well recognised. whose rectal temperature is more than 101°F, there is a great risk of fatal hyperpyrexial reactions ; but if no infusion is given, the patient will probably die of irreversible shock.
1. Wood, B. S. B. Lancet, 1952, i, 28. 2. Wickes, I. G. Brit. med. J. 1952, ii, 1178. 3. Illingworth, R. S. The Normal Child ; p. 74. London, 1953. 4. Ogilvie, H. Ann. R. Coll. Surg. Engl. 1957, 21, 319.
1. Rogers, L. Cholera and its Treatment. London, 1913. Bowel Diseases in the Tropics. 2. Rogers, L. London, 1921. 3. Chatterjee, H. N., Chatterjee, K. K., Saha, R. K., Banerjee, R., Basu, D. K., Gupta, J. C., Ghosh, H. Antiseptic, 1955, 52, 85.
sometimes
a
symptoms. On