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ACTION OF ANTIBIOTICS
487 of lead in the first case is not yet definitely the second child had ingested lead from but established, the old and crumbling paintwork of an outside balcony. The lead content of the paint was 54% (calculated as the metal). There is clearly a need for more safeguards against this danger than exist at present.
The
source
Whittington Hospital, London, N.19.
M. B. MORRIS.
ACTION OF ANTIBIOTICS SIR,—Iconsider it dangerous to let your interesting leading article of Aug. 23 pass without comment, especially in so far as penicillin action is concerned. That penicillin affects the assimilation of glutamic acid is beyond doubt, but it is equally beyond doubt that*death of the cell does not come about because it has been deprived of the vital preformed glutamic acid.
Many penicillin-sensitive staphylococci will grow without added glutamic acid and a Bacillus subtilis has been described which is extremely sensitive to penicillin, even when growing on a medium composed of inorganic salts and glucose only. Thus, we can have both penicillinsensitive and penicillin-resistant organisms which are nutritionally independent of preformed glutamic acid or of any other amino acid. Dr. E. F. Gale, who has done such excellent work on this subject, has wisely avoided jumping to the easy conclusions which you expound. In spite of the tremendous amount of work done in the last few years on the mode of action of antibiotics, are far from understanding how any of them works. Wright-Fleming Institute of Microbiology, St. Mary’s Hospital Medical School, London, W. 2.
we
DERKICK ROWLEY.
ATTENDANCE AT BOXING CONTESTS SIR,—We are anxious to obtain the voluntary services of medical men to attend amateur boxing shows in London and the suburbs during the coming autumn and winter. The shows usually take place in the evening, and the duties consist in examining the contestants (total time ½—3/4 hour) and being available or on call for any serious injuries, which are usually very few. The only reward we can offer is a good boxing show and a convivial evening. Medical officers will have the satisfaction of knowing that they are assisting to foster a high physical and moral standard in the health of the nation’s youth.
Will doctors who
are
interested
London Amateur Boxing Association, 69, Victoria Street, London, S.W.1.
please write to
me ?
J. L. BLONSTEIN Hon. Medical Officer.
BLOOD-PRESSURE ESTIMATIONS IN CHILDREN SIR,—Your explanation (Aug. 16) that you were referring to research conditions in your leading article on the treatment of bacterial meningitis disposes at once of two of my objections to your proposed scheme of hiood-pressure estimations—namely, that child manometer cuffs are not generally available, and that the suggested procedure would prove appallingly timeconsuming. But not, I think, of my third, and perhaps most important, objection-that in most cases even when a reading has been obtained its value is doubtful. The Waterhouse-Friderichsen syndrome occurs predominantly in young children, often very young children. Though desperately ill they are not, unless in the terminal stages, inert ; on the contrary they are restless and resistive. They struggle against the manometer cuff and have to be firmly held. Of what value are readings obtained under such restraintAnd are we justified in provoking these patients to expend their diminishing nerves of strength for the sake of such equivocal findings t By all means let us have as many accurate estimations as we can in patients; I agree that they afford valuable confirma-
blood-pressure
catiperative
in diagnosis. But diagnosis is not so difficult as suggested, and, with respect, has seldom to be made from other very severe forms of ordinary meningitis, for in fact there is little similarity between the two conditions. The crucial feature of the Waterhouse-Friderichsen syndrome is that signs of meningitis are either extremely slight or, more usually, absent, and the conditions usually suggested to the clinician are malignant purpura or pneumonia. Perhaps I can make my position clearer if I say that in my view any patient who presents with collapse and
tory evidence
a
purpuric
or
ecchymotic (not petechial) rash, particularly
if there is livid cyanosis and perhaps polypnœa, should have a lumbar puncture. If this reveals an opalescent or turbid fluid under increased pressure, cortisone and sulphonamides should be given without delay; for this is one of the most acute emergencies in medicineone has seen a patient die within 12 hours of taking ill. The amount of cortisone required is relatively negligible. I agree that its value in this syndrome should be most carefully assessed ; but I submit that this has already been shown to be considerable ; and if we are to wait until correct blood-pressure estimations have been made, then I submit, Sir, that many lives will be lost that might otherwise he saved. South Middlesex Hospital, Isleworth.
CAROB
G. E. BREEN.
FLOUR IN FUNCTIONAL VOMITING OF INFANTS
SIR,—Most babies who frequently vomit or regurgitate their food are just mild " posseters," but a few belong to the more serious and even alarming class of " habitual vomiters." These babies may reject their food any time within an hour of feeding. The trouble may start very soon after birth in either breast- or bottle-fed children. When an organic cause has been excluded, the diagnosis of " habitual vomiting " may reasonably be made. This is a functional disturbance of ingestion which includes cardio-oesophageal relaxation.1 The problem of getting the baby to retain its food must then be tackled. Most infants come to no harm from occasional or even quite regular vomiting, but the baby whose weight stays the same or actually falls is in danger, and undernourishment may lead to dehydration and atrophy. And in spite of this the infant is hungry, alert, and avid for food which it cannot hold. The usual treatment is to thicken the food by adding, say, wheat flour or arrowroot to the milk formula or to the expressed breast-milk, thereby increasing the viscosity of the milk and helping to keep it in the stomach. Phenobarbitone may also be given before each feed. These measures usually work in the simpler cases. Fineoatmeal gruel and pureed potato made with milk are sometimes used, or the consistence of the feed may be suitably altered by using powdered or condensed milks, extra fluid being given as water between feeds. Whatever method is used there is an important disadvantage-the formula is poorly balanced for the infant’s nutritional needs, and growth may be affected. It was with much relief that I heard of Professor Lelong’s work in Paris on this problem. All degrees of persistent functional emesis in infants were treated with milk thickened by the addition of carob flour, a powder extracted from the seed of the Levantine carob tree. Information about this legume, Ceratonia siliqua (Linne), is given by Glanzmann.2 This flour was prepared for Professor Lelong’s trials by the Nestlé Company of Switzerland, and has proved indispensable. Its virtues are that it has no flavour, it thickens the milk without lessening its digestibility or changing its nutritive value, and it is completely inert and neutral. But it does alter 1. Neuhauser, E. B. D.. Berenberg. W. 2. Glanzmann, E. Einführung in die 1949; p. 220.
Radiology, 1947, 48, 480. Kinderheilkunde. Vienna,
The
source
Whittington Hospital, London, N.19.
M. B. MORRIS.
ACTION OF ANTIBIOTICS SIR,—Iconsider it dangerous to let your interesting leading article of Aug. 23 pass without comment, especially in so far as penicillin action is concerned. That penicillin affects the assimilation of glutamic acid is beyond doubt, but it is equally beyond doubt that*death of the cell does not come about because it has been deprived of the vital preformed glutamic acid.
Many penicillin-sensitive staphylococci will grow without added glutamic acid and a Bacillus subtilis has been described which is extremely sensitive to penicillin, even when growing on a medium composed of inorganic salts and glucose only. Thus, we can have both penicillinsensitive and penicillin-resistant organisms which are nutritionally independent of preformed glutamic acid or of any other amino acid. Dr. E. F. Gale, who has done such excellent work on this subject, has wisely avoided jumping to the easy conclusions which you expound. In spite of the tremendous amount of work done in the last few years on the mode of action of antibiotics, are far from understanding how any of them works. Wright-Fleming Institute of Microbiology, St. Mary’s Hospital Medical School, London, W. 2.
we
DERKICK ROWLEY.
ATTENDANCE AT BOXING CONTESTS SIR,—We are anxious to obtain the voluntary services of medical men to attend amateur boxing shows in London and the suburbs during the coming autumn and winter. The shows usually take place in the evening, and the duties consist in examining the contestants (total time ½—3/4 hour) and being available or on call for any serious injuries, which are usually very few. The only reward we can offer is a good boxing show and a convivial evening. Medical officers will have the satisfaction of knowing that they are assisting to foster a high physical and moral standard in the health of the nation’s youth.
Will doctors who
are
interested
London Amateur Boxing Association, 69, Victoria Street, London, S.W.1.
please write to
me ?
J. L. BLONSTEIN Hon. Medical Officer.
BLOOD-PRESSURE ESTIMATIONS IN CHILDREN SIR,—Your explanation (Aug. 16) that you were referring to research conditions in your leading article on the treatment of bacterial meningitis disposes at once of two of my objections to your proposed scheme of hiood-pressure estimations—namely, that child manometer cuffs are not generally available, and that the suggested procedure would prove appallingly timeconsuming. But not, I think, of my third, and perhaps most important, objection-that in most cases even when a reading has been obtained its value is doubtful. The Waterhouse-Friderichsen syndrome occurs predominantly in young children, often very young children. Though desperately ill they are not, unless in the terminal stages, inert ; on the contrary they are restless and resistive. They struggle against the manometer cuff and have to be firmly held. Of what value are readings obtained under such restraintAnd are we justified in provoking these patients to expend their diminishing nerves of strength for the sake of such equivocal findings t By all means let us have as many accurate estimations as we can in patients; I agree that they afford valuable confirma-
blood-pressure
catiperative
in diagnosis. But diagnosis is not so difficult as suggested, and, with respect, has seldom to be made from other very severe forms of ordinary meningitis, for in fact there is little similarity between the two conditions. The crucial feature of the Waterhouse-Friderichsen syndrome is that signs of meningitis are either extremely slight or, more usually, absent, and the conditions usually suggested to the clinician are malignant purpura or pneumonia. Perhaps I can make my position clearer if I say that in my view any patient who presents with collapse and
tory evidence
a
purpuric
or
ecchymotic (not petechial) rash, particularly
if there is livid cyanosis and perhaps polypnœa, should have a lumbar puncture. If this reveals an opalescent or turbid fluid under increased pressure, cortisone and sulphonamides should be given without delay; for this is one of the most acute emergencies in medicineone has seen a patient die within 12 hours of taking ill. The amount of cortisone required is relatively negligible. I agree that its value in this syndrome should be most carefully assessed ; but I submit that this has already been shown to be considerable ; and if we are to wait until correct blood-pressure estimations have been made, then I submit, Sir, that many lives will be lost that might otherwise he saved. South Middlesex Hospital, Isleworth.
CAROB
G. E. BREEN.
FLOUR IN FUNCTIONAL VOMITING OF INFANTS
SIR,—Most babies who frequently vomit or regurgitate their food are just mild " posseters," but a few belong to the more serious and even alarming class of " habitual vomiters." These babies may reject their food any time within an hour of feeding. The trouble may start very soon after birth in either breast- or bottle-fed children. When an organic cause has been excluded, the diagnosis of " habitual vomiting " may reasonably be made. This is a functional disturbance of ingestion which includes cardio-oesophageal relaxation.1 The problem of getting the baby to retain its food must then be tackled. Most infants come to no harm from occasional or even quite regular vomiting, but the baby whose weight stays the same or actually falls is in danger, and undernourishment may lead to dehydration and atrophy. And in spite of this the infant is hungry, alert, and avid for food which it cannot hold. The usual treatment is to thicken the food by adding, say, wheat flour or arrowroot to the milk formula or to the expressed breast-milk, thereby increasing the viscosity of the milk and helping to keep it in the stomach. Phenobarbitone may also be given before each feed. These measures usually work in the simpler cases. Fineoatmeal gruel and pureed potato made with milk are sometimes used, or the consistence of the feed may be suitably altered by using powdered or condensed milks, extra fluid being given as water between feeds. Whatever method is used there is an important disadvantage-the formula is poorly balanced for the infant’s nutritional needs, and growth may be affected. It was with much relief that I heard of Professor Lelong’s work in Paris on this problem. All degrees of persistent functional emesis in infants were treated with milk thickened by the addition of carob flour, a powder extracted from the seed of the Levantine carob tree. Information about this legume, Ceratonia siliqua (Linne), is given by Glanzmann.2 This flour was prepared for Professor Lelong’s trials by the Nestlé Company of Switzerland, and has proved indispensable. Its virtues are that it has no flavour, it thickens the milk without lessening its digestibility or changing its nutritive value, and it is completely inert and neutral. But it does alter 1. Neuhauser, E. B. D.. Berenberg. W. 2. Glanzmann, E. Einführung in die 1949; p. 220.
Radiology, 1947, 48, 480. Kinderheilkunde. Vienna,