- Email: [email protected]
INFANTILE GASTROENTERITIS
219
the cortisone withdrawal syndrome in its form. In our unit we give written instructions to patients and send a copy to their practitioners emphasising that steroid therapy must not be interrupted and that if the patient cannot take his tablets by mouth during an episode of acute gastric enteritis, cortisone must be given intramuscularly. Should an operation be necessary, dosage of cortisone must be stepped up before, during, and after the operation, for surgical operations are a form of stress and all forms of stress call for increased dosage. We have recently seen cases of peripheral neuritis developing after suddenly stopping steroid therapy and several severe and even fatal cases of withdrawal syndrome are on record as quoted by Dr. Davis and Dr. Popert. cases
most
that
we see
flamboyant
All this has been well described and emphasised for some years but the fact remains that these points are perhaps not sufficiently widely appreciated even today, and Dr. Davis and Dr. Popert’s article is, therefore, both timelv and imDortant. F. DUDLEY HART. MEDICAL PRACTICE IN A CHANGING SOCIETY SIR,-It is with dismay and despair I read Sir Francis Fraser pontificating in his article in your issue of Jan. 18. Of course, we would like to have a secretary and a receptionist to do our non-medical work. Of course, we would prefer to improve our standard of care by spending more time on fewer patients. How is this to be done when we are paid seventeen shillings and sixpence a year for our five or six items of service, working out at half a crown or three shillings a time ? A plumber who came on a Sunday, a few weeks ago, to unblock a drain demanded a pound before starting work-a not unreasonable fee-but let Sir Francis realise, we are valued by the State at no more than one-eighth the worth of a plumber. It makes us smart to be told that we must try and do better medicine, when we cannot produce a higher standard of care unless we are adequately paid to do so. We have to pay our rent and our children’s school fees. The Government has appointed a Royal Commission, and our two-year-old pay claim-the first since 1951-has been ignored. The heartbreaking delay has been perpetuated, and there seems little likelihood of.any pay increase and implementation of Sir Francis Fraser’s pious suggestions for a decade or more. P. F. KENNISH. REGULATION OF BODY TEMPERATURE
SIR,-Iwas interested to learn from the recent contribution of Sir George Pickering (Jan. 4 and 11) that the relatively high temperature of the rectum suggests that it may be a source of heat production by bacterial metabolism in fxces. Some evidence of heat generated from this source has been found in the temperate species of tortoises which are at present being studied. With low environmental temperatures torpidity is induced which results in hibernation and it is not of uncommon occurrence that specimens with any considerable amount of fasces in the upper part of their rectum will after several weeks of hibernation awaken although the environmental temperature is below that permitting comfortable voluntary activity. On the other hand, specimens which have a comparatively empty rectum do not usually awaken. Presumably the bacterial metabolism which is thermogenic raises the body temperature of small individuals to that required for voluntary activities. We find that with adult specimens with a as
loaded
there is seldom awakening from hibernation, it is a greater task to warm a larger body by this
rectum
probably
source. This latter observation suggests that awakening from hibernation is not a result of any perineal sensation which induces defxcation. Unfortunately it has not as yet been possible to record the amount of heat evolved by the fxces while within the body, but it appears that a juvenile specimen hibernating with a loaded rectum will, in a period of between four and seven weeks, at an external environmental temperature of 11°C, have an anal canal temperature 4°C above that of a specimen with an empty rectum. This and related problems are to be
investigated. The rapidly changing immediate environmental conditions within the rectum of any animal, including man, will unfortunately never give a reliable temperature reading for any given period. The belief of Mead and Bonmaritoi is that the temperature of any region depends on the metabolic activity of the region; the temperature and amount of blood flowing through the region and the gradients of temperature to surrounding regions will never allow the rectal temperature to be as precise as some have in the past thought. This would apply to all parts of the body for there is no organ, tissues, or cells which have the same metabolic activity all the time. Zoological Society of London, London, N.W.1.
TIMOTHY
J. HUNT.
SIR,-I read with great interest Sir George Pickering’s thought-provoking articles.
excellent and
He mentions that " the considerable interval between the entry of endogenous pyrogen into the blood-stream and the onset of fever suggests the formation of a further intermediate Considerable interval is rather vague and I substance." wonder what the actual figures were. It is often observed that patients have rigors soon after starting intravenous fluids, in spite of adequate aseptic precautions; this is in all probability an unknown pyrogen reaction. My limited observations of treatment with intravenous T.A.B. vaccine, in gradually increasing doses, suggest that rigors almost always start in 15-30 minutes or not at all. Is this a considerable interval for the formation of an intermediate substance ? Victoria Hospital, S. S. JHAVERI. Accrington. "
"
INFANTILE GASTROENTERITIS
SIR,-Dr. Librach (Jan. 11) appears to have missed the point of our article (Dec. 14). Infantile gastroenteritis due to Escherichia coli is a specific disease with known high infectivity. Careful bacteriological examination of the stools to exclude the known pathogenic serotypes of Esch. coli in a case of infantile diarrhoea and vomiting is essential before one is entitled to consider the ill-defined field of infantile digestive disorders. Our experience suggests that many cases which on clinical grounds appear to be of the non-infective type actually prove to be mild cases of infective gastroenteritis. Mild cases of infantile gastroenteritis due to Esch. coli treated at home often do well without any antibiotics at all. In hospital the problem is somewhat different and the need for treatment of proved cases falls into three
categories: Where the clinical condition warrants it (all severe and many of the intermediate group). In severe cases we consider that antibiotic therapy should be started as soon as a stool sample has been obtained, and before the results are available. (b) Those cases from institutions and nurseries where negative stools are required before discharge. (c) Mild cases from their own homes in order to reduce the chance of cross-infection. It is in this last category that
(a)
cases
opinions
may vary.
Treatment on these lines 4s antibiotic therapy ". 1.
surely not " indiscriminate
Mead, J., Bonmarito, C. L. J. appl. Physiol. 1949, 2, 97.
220 We were surprised that Professor Watkins (Dec. 21) is " not impressed with the therapeutic effectiveness of antibiotics ", but perhaps he was referring to all grades of severity. In severe cases the ease of treatment and the rapid recovery bear no comparison with the difficulties encountered before the advent of antibiotics. Infantile gastroenteritis should be treated on the knowledge of the bacteriological facts and not on clinical impressions. It would avoid confusion if this term was used only in those cases in which known serotypes of Esch. coli
were
isolated.
Hither Green Hospital, London, S.E.13.
E. H. BROWN E. H. BAILEY.
A FUNCTIONAL NECESSITY
SIR,-Mr. Murley’s letter in
your last issue
seems more
concerned with attacking the Regional Board and its officers than attempting to deal with the extremely difficult problem of medical staffing in the hospitals. As he quotes from correspondence with the Board, your readers will be interested to see, in full, the request which he made for information to be supplied to the Medical Committee. This was : 1. The numbers of consultants and s.H.M.o.s in the various at present working in the region. 2. The number of requests for additional consultant staff received from hospital management and/or medical advisory committees since 1948. 3. The number of such requests which the Board has been (a) able to fill, or (b) unable to advertise. 4. The number of additional consultant appointments made by the Board without specific request from the periphery. 5. The number of requests for additional consultant appointments or additional sessions, emanating from management committees or medical advisory committees which the Board has not agreed to. 6. The number of requests for additional consultant appointments, &c., which the Board has not been able to advertise owing to financial stringency. (It being presumed that the Board would like to have made these appointments had the money been available.) 7. The number of s.H.M.o.s who are performing consultant work. 8. The number of senior registrars who are " time expired " and seeking consultant appointments. 9. Finally, may the medical committee please be supplied with details of any investigations of the medical needs of the region which have been undertaken by representatives of the Board, the Ministry or any other group which has looked into this matter.
specialties
Murley quotes only an extract from the written reply. The reply forwarded to him in fact reads as Mr.
follows: " The information requested by him would be most difficult to assemble and would involve a close examination of all the Board’s records on medical staffing since 1948-this in itself would be a major undertaking. It would then be necessary to analyse them in some detail and the result would still not be satisfactory since in many cases, it would be a matter of opinion as to the net effect of a particular line of action by the Board. Quite apart from this, the Board’s staff is so sorely pressed at the present time, that to embark on this project for Mr. Murley would be quite impossible." "
This difficult question of the most appropriate medical staffing of the hospitals has been concerning the medical staffing subcommittee of the Board’s Establishment Committee for a considerable period of time. This subcommittee consists of six members, five of whom are
medical. On Oct. 16, 1957, the Board sent a deputation to the Ministry of Health asking that most urgent consideration should be given to a number of problems affecting medical staffing, particularly one arising out of the present difficulty over senior registrars, and suggesting a number of solutions. The fact that the Ministry of Health have not so far been able to meet the Board in the suggestions
which it made, is perhaps due to the intractable nature of the problem as between the Ministry of Health and the
profession
as a
whole.
North West
Metropolitan Regional Hospital Board, 11a, Portland Place, London, W.1.
COTTESLOE Chairman.
MANIPULATION FOR BACKACHE
SIR,-Mr. Bremner (Jan. 4) defines lumbosacral strain as a chronic localised disc degeneration with associated derangement of the corresponding posterior joints and ligaments from which pain presumably arises; in the early stages it is a subluxation or instability of the posterior joints with associated ligamentous strain and in later stages a true osteoarthritis. (Nerve-root involvement and general spondylosis are excluded.) The long-term management is arranged as follows: (1) If seriously disabling: spinal fusion. (2) If not seriously disabling: (a) Reassurance and advice on how " to live with their back ", if intelligent. (b) Manipulation for the average hospital patient because he something more " positive " than reassurance and advice, and if not given manipulation he will seek it expects
elsewhere.
The reasons given for manipulation under (2b) have no foundation in pathology and could equally well be put forward as arguments for treating with strapping, plaster, corset, local anaesthetic, cortisone, or even an X-ray! As " a priori " arguments for manipulation, they have no value. In addition there is nothing in Mr. Bremner’s concept of the pathology to justify manipulation. If manipulation is to have any objective value as distinct from psychological it must mean either a purposeful and enduring correction of a derangement or the restoration of all or part of a range of movement lost through adhesions. It would seem that Mr. Bremner realises all this and he attempts to justify the use of manipulation on the purely " empirical grounds that it produces " satisfied customers without having any scientific explanation for this. Given the pathology as described by Mr. Bremner I cannot understand how 25 of his 250 cases obtained dramatic relief from (presumably) a single manipulation (unless the result was due to the subsequent physiotherapy). I find it much easier to understand why 61 of his patients found relief only ina lumbosacral corset.
I make these observations not in criticism of Mr. Bremner’s article, since he is assiduously careful to avoid making any claim to diagnose with scientific evidence any derangement of the lumbosacral region which he would profess to be able to purposefully correct by a specially designed manipulative procedure. My disagreement is rather with those who advocate a practice which implies such a claim. Of this school of thought I would ask: (1) What precisely in anatomical terms do you attempt when
manipulate ? It seems to be more generally the hypothesis that there is a derangement rather than adhesions. (2) How do you achieve a precise correction of a unit of the intricate lumbosacral complex by a manoeuvre exercised on the exterior of the trunk ? I can diagnose with X rays a dislocation of the fifth cervical vertebra on the sixth cervical vertebra and reduce it by a manoeuvre based on a knowledge of the method of production of the derangement and check my result by X-ray examination, but I cannot practise in this manner on hypothetical derangements of the lumbosacral-joint complex for which I have no objective evidence. (3) Is it right that throughout the country practitioners should manipulate " slipped discs " if many of them have no personal experience of the nature of a protrusion of the nucleus pulposus as seen at operation ? Of some hundreds of disc protrusions I have seen at operation I have never seen one that could be reduced by manipulation. Perhaps it is only the
you
the cortisone withdrawal syndrome in its form. In our unit we give written instructions to patients and send a copy to their practitioners emphasising that steroid therapy must not be interrupted and that if the patient cannot take his tablets by mouth during an episode of acute gastric enteritis, cortisone must be given intramuscularly. Should an operation be necessary, dosage of cortisone must be stepped up before, during, and after the operation, for surgical operations are a form of stress and all forms of stress call for increased dosage. We have recently seen cases of peripheral neuritis developing after suddenly stopping steroid therapy and several severe and even fatal cases of withdrawal syndrome are on record as quoted by Dr. Davis and Dr. Popert. cases
most
that
we see
flamboyant
All this has been well described and emphasised for some years but the fact remains that these points are perhaps not sufficiently widely appreciated even today, and Dr. Davis and Dr. Popert’s article is, therefore, both timelv and imDortant. F. DUDLEY HART. MEDICAL PRACTICE IN A CHANGING SOCIETY SIR,-It is with dismay and despair I read Sir Francis Fraser pontificating in his article in your issue of Jan. 18. Of course, we would like to have a secretary and a receptionist to do our non-medical work. Of course, we would prefer to improve our standard of care by spending more time on fewer patients. How is this to be done when we are paid seventeen shillings and sixpence a year for our five or six items of service, working out at half a crown or three shillings a time ? A plumber who came on a Sunday, a few weeks ago, to unblock a drain demanded a pound before starting work-a not unreasonable fee-but let Sir Francis realise, we are valued by the State at no more than one-eighth the worth of a plumber. It makes us smart to be told that we must try and do better medicine, when we cannot produce a higher standard of care unless we are adequately paid to do so. We have to pay our rent and our children’s school fees. The Government has appointed a Royal Commission, and our two-year-old pay claim-the first since 1951-has been ignored. The heartbreaking delay has been perpetuated, and there seems little likelihood of.any pay increase and implementation of Sir Francis Fraser’s pious suggestions for a decade or more. P. F. KENNISH. REGULATION OF BODY TEMPERATURE
SIR,-Iwas interested to learn from the recent contribution of Sir George Pickering (Jan. 4 and 11) that the relatively high temperature of the rectum suggests that it may be a source of heat production by bacterial metabolism in fxces. Some evidence of heat generated from this source has been found in the temperate species of tortoises which are at present being studied. With low environmental temperatures torpidity is induced which results in hibernation and it is not of uncommon occurrence that specimens with any considerable amount of fasces in the upper part of their rectum will after several weeks of hibernation awaken although the environmental temperature is below that permitting comfortable voluntary activity. On the other hand, specimens which have a comparatively empty rectum do not usually awaken. Presumably the bacterial metabolism which is thermogenic raises the body temperature of small individuals to that required for voluntary activities. We find that with adult specimens with a as
loaded
there is seldom awakening from hibernation, it is a greater task to warm a larger body by this
rectum
probably
source. This latter observation suggests that awakening from hibernation is not a result of any perineal sensation which induces defxcation. Unfortunately it has not as yet been possible to record the amount of heat evolved by the fxces while within the body, but it appears that a juvenile specimen hibernating with a loaded rectum will, in a period of between four and seven weeks, at an external environmental temperature of 11°C, have an anal canal temperature 4°C above that of a specimen with an empty rectum. This and related problems are to be
investigated. The rapidly changing immediate environmental conditions within the rectum of any animal, including man, will unfortunately never give a reliable temperature reading for any given period. The belief of Mead and Bonmaritoi is that the temperature of any region depends on the metabolic activity of the region; the temperature and amount of blood flowing through the region and the gradients of temperature to surrounding regions will never allow the rectal temperature to be as precise as some have in the past thought. This would apply to all parts of the body for there is no organ, tissues, or cells which have the same metabolic activity all the time. Zoological Society of London, London, N.W.1.
TIMOTHY
J. HUNT.
SIR,-I read with great interest Sir George Pickering’s thought-provoking articles.
excellent and
He mentions that " the considerable interval between the entry of endogenous pyrogen into the blood-stream and the onset of fever suggests the formation of a further intermediate Considerable interval is rather vague and I substance." wonder what the actual figures were. It is often observed that patients have rigors soon after starting intravenous fluids, in spite of adequate aseptic precautions; this is in all probability an unknown pyrogen reaction. My limited observations of treatment with intravenous T.A.B. vaccine, in gradually increasing doses, suggest that rigors almost always start in 15-30 minutes or not at all. Is this a considerable interval for the formation of an intermediate substance ? Victoria Hospital, S. S. JHAVERI. Accrington. "
"
INFANTILE GASTROENTERITIS
SIR,-Dr. Librach (Jan. 11) appears to have missed the point of our article (Dec. 14). Infantile gastroenteritis due to Escherichia coli is a specific disease with known high infectivity. Careful bacteriological examination of the stools to exclude the known pathogenic serotypes of Esch. coli in a case of infantile diarrhoea and vomiting is essential before one is entitled to consider the ill-defined field of infantile digestive disorders. Our experience suggests that many cases which on clinical grounds appear to be of the non-infective type actually prove to be mild cases of infective gastroenteritis. Mild cases of infantile gastroenteritis due to Esch. coli treated at home often do well without any antibiotics at all. In hospital the problem is somewhat different and the need for treatment of proved cases falls into three
categories: Where the clinical condition warrants it (all severe and many of the intermediate group). In severe cases we consider that antibiotic therapy should be started as soon as a stool sample has been obtained, and before the results are available. (b) Those cases from institutions and nurseries where negative stools are required before discharge. (c) Mild cases from their own homes in order to reduce the chance of cross-infection. It is in this last category that
(a)
cases
opinions
may vary.
Treatment on these lines 4s antibiotic therapy ". 1.
surely not " indiscriminate
Mead, J., Bonmarito, C. L. J. appl. Physiol. 1949, 2, 97.
220 We were surprised that Professor Watkins (Dec. 21) is " not impressed with the therapeutic effectiveness of antibiotics ", but perhaps he was referring to all grades of severity. In severe cases the ease of treatment and the rapid recovery bear no comparison with the difficulties encountered before the advent of antibiotics. Infantile gastroenteritis should be treated on the knowledge of the bacteriological facts and not on clinical impressions. It would avoid confusion if this term was used only in those cases in which known serotypes of Esch. coli
were
isolated.
Hither Green Hospital, London, S.E.13.
E. H. BROWN E. H. BAILEY.
A FUNCTIONAL NECESSITY
SIR,-Mr. Murley’s letter in
your last issue
seems more
concerned with attacking the Regional Board and its officers than attempting to deal with the extremely difficult problem of medical staffing in the hospitals. As he quotes from correspondence with the Board, your readers will be interested to see, in full, the request which he made for information to be supplied to the Medical Committee. This was : 1. The numbers of consultants and s.H.M.o.s in the various at present working in the region. 2. The number of requests for additional consultant staff received from hospital management and/or medical advisory committees since 1948. 3. The number of such requests which the Board has been (a) able to fill, or (b) unable to advertise. 4. The number of additional consultant appointments made by the Board without specific request from the periphery. 5. The number of requests for additional consultant appointments or additional sessions, emanating from management committees or medical advisory committees which the Board has not agreed to. 6. The number of requests for additional consultant appointments, &c., which the Board has not been able to advertise owing to financial stringency. (It being presumed that the Board would like to have made these appointments had the money been available.) 7. The number of s.H.M.o.s who are performing consultant work. 8. The number of senior registrars who are " time expired " and seeking consultant appointments. 9. Finally, may the medical committee please be supplied with details of any investigations of the medical needs of the region which have been undertaken by representatives of the Board, the Ministry or any other group which has looked into this matter.
specialties
Murley quotes only an extract from the written reply. The reply forwarded to him in fact reads as Mr.
follows: " The information requested by him would be most difficult to assemble and would involve a close examination of all the Board’s records on medical staffing since 1948-this in itself would be a major undertaking. It would then be necessary to analyse them in some detail and the result would still not be satisfactory since in many cases, it would be a matter of opinion as to the net effect of a particular line of action by the Board. Quite apart from this, the Board’s staff is so sorely pressed at the present time, that to embark on this project for Mr. Murley would be quite impossible." "
This difficult question of the most appropriate medical staffing of the hospitals has been concerning the medical staffing subcommittee of the Board’s Establishment Committee for a considerable period of time. This subcommittee consists of six members, five of whom are
medical. On Oct. 16, 1957, the Board sent a deputation to the Ministry of Health asking that most urgent consideration should be given to a number of problems affecting medical staffing, particularly one arising out of the present difficulty over senior registrars, and suggesting a number of solutions. The fact that the Ministry of Health have not so far been able to meet the Board in the suggestions
which it made, is perhaps due to the intractable nature of the problem as between the Ministry of Health and the
profession
as a
whole.
North West
Metropolitan Regional Hospital Board, 11a, Portland Place, London, W.1.
COTTESLOE Chairman.
MANIPULATION FOR BACKACHE
SIR,-Mr. Bremner (Jan. 4) defines lumbosacral strain as a chronic localised disc degeneration with associated derangement of the corresponding posterior joints and ligaments from which pain presumably arises; in the early stages it is a subluxation or instability of the posterior joints with associated ligamentous strain and in later stages a true osteoarthritis. (Nerve-root involvement and general spondylosis are excluded.) The long-term management is arranged as follows: (1) If seriously disabling: spinal fusion. (2) If not seriously disabling: (a) Reassurance and advice on how " to live with their back ", if intelligent. (b) Manipulation for the average hospital patient because he something more " positive " than reassurance and advice, and if not given manipulation he will seek it expects
elsewhere.
The reasons given for manipulation under (2b) have no foundation in pathology and could equally well be put forward as arguments for treating with strapping, plaster, corset, local anaesthetic, cortisone, or even an X-ray! As " a priori " arguments for manipulation, they have no value. In addition there is nothing in Mr. Bremner’s concept of the pathology to justify manipulation. If manipulation is to have any objective value as distinct from psychological it must mean either a purposeful and enduring correction of a derangement or the restoration of all or part of a range of movement lost through adhesions. It would seem that Mr. Bremner realises all this and he attempts to justify the use of manipulation on the purely " empirical grounds that it produces " satisfied customers without having any scientific explanation for this. Given the pathology as described by Mr. Bremner I cannot understand how 25 of his 250 cases obtained dramatic relief from (presumably) a single manipulation (unless the result was due to the subsequent physiotherapy). I find it much easier to understand why 61 of his patients found relief only ina lumbosacral corset.
I make these observations not in criticism of Mr. Bremner’s article, since he is assiduously careful to avoid making any claim to diagnose with scientific evidence any derangement of the lumbosacral region which he would profess to be able to purposefully correct by a specially designed manipulative procedure. My disagreement is rather with those who advocate a practice which implies such a claim. Of this school of thought I would ask: (1) What precisely in anatomical terms do you attempt when
manipulate ? It seems to be more generally the hypothesis that there is a derangement rather than adhesions. (2) How do you achieve a precise correction of a unit of the intricate lumbosacral complex by a manoeuvre exercised on the exterior of the trunk ? I can diagnose with X rays a dislocation of the fifth cervical vertebra on the sixth cervical vertebra and reduce it by a manoeuvre based on a knowledge of the method of production of the derangement and check my result by X-ray examination, but I cannot practise in this manner on hypothetical derangements of the lumbosacral-joint complex for which I have no objective evidence. (3) Is it right that throughout the country practitioners should manipulate " slipped discs " if many of them have no personal experience of the nature of a protrusion of the nucleus pulposus as seen at operation ? Of some hundreds of disc protrusions I have seen at operation I have never seen one that could be reduced by manipulation. Perhaps it is only the
you