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INFANTILE GASTROENTERITIS
533
anaesthesia.
Very occasionally, the onset was related to operation performed under general anaesthesia and this must be mentioned even though it appears to destroy the force of my argument. However, some of these the involved lithotomy position. Since the operations number of operations performed under spinal anaesthesia has dropped this history has not been obtained. It was these cases, more than anything else, which caused me to prohibit the use of spinal anaesthetics for my patients. an
W. SAYLE-CREER.
Manchester.
INFANTILE GASTROENTERITIS
SIR,-Dr. Librach (Feb. 22) has made it abundantly plain that he does not believe in the pathogenicity of serotypes of Escherichia coli in infantile enteritis. Héemophilus infiuenzae, he says, was once held to be the cause of influenza, now known to be a virus disease; therefore, the laboratory has misled and hindered the clinician. He then implies that the laboratory work on the serology of Esch. coli has done a similar disservice to medicine by confusing rather than explaining the xtiology of infective enteritis in infants. He does not disclose his reasons for doubting all the work which has been published on the subject during the past 10 years. He has quoted a passage from a paper1 of which I was one of the authors. Lifted out of its context this quotation would suggest that the authors themselves doubted the significance of finding Esch. coli type 0.111 in infantile enteritis. This is not the case; the quoted passage does not represent the thesis of the paper in question, nor does it reflect the views of its authors at the time when it was written, much less so now.
City General Hospital, Stoke-on-Trent.
C. GILES.
SUDDEN DEAFNESS
SIR,-Mr. Boyes Korkis (Feb. 22) rightly stresses the need for treating patients with sudden perceptive deafness "as an absolute emergency ". He goes on to say that " a therapeutic trial of a stellate block would yield useful information and if carried out early enough would have a greater chance of success ". I can assure Mr. Korkis it not only would but does. Like Mr. Korkis, I do not advocate the use of intravenous nicotinic acid because I cannot see the advantage of this over a stellate block. Audiograms should be done immediately before the block and half an hour after under good conditions by a skilled technician in every case, and an efficient vasodilator drug-I use buphenine (’Perdilatal ’)-plays (not " could play ") an important part in maintaining the good effect of a successful stellate block. Mr. Korkis goes on to say that the old expectant attitude in sudden deafness of this type must change to one of action. I agree, but it must change similarly in the treatment of Meniere’s disease.2 Having done about 600 stellate blocks for inner-ear disorders during the past five years, under ideal audiometric conditions, having produced on many occasions a significant rise in hearing by stellate block, and having demonstrated by visual observation and lately by nystagmography the complete return of vestibular function after sympathetcomy, I am convinced that many cases of sudden deafness of percep1. 2.
Giles, C., Sangster, G. J. Hyg., Camb. 1948, 46, 1. Wilmot, T. J. Brit. med. J. 1957, ii, 1047.
tive
type-especially in young patients-have an aetiology essentially similar to that of Meniere’s disease, and that the new approach to these disorders, first demonstrated by Mr. E. Garnett Passe, has gone for too long without recognition. T. J. WILMOT. Tyrone County Hospital. SIR,-May
CLINICAL GERIATRICS I thank and commend you for your annota-
tion on this topic last week ? The special problems associated with the care of elderly patients are not known as well as they might be. The present medical curriculum gives students little teaching and less experience in this branch of medicine. In consequence, when they go into practice, they find themselves confronted with unfamiliar situations for which they have not been prepared by their teachers. Is it not time to press for more clinical instruction in geriatrics ? Surely the changes in our population make the care of elderly patients one of the most important tasks confronting our profession in this day and age. TREVOR H. HOWELL. London, S.W.16. SOFT-TISSUE RADIOGRAPHY IN ESTIMATING FŒTAL MATURITY AND POSTMATURITY
SiR,ŅYour leading article of Feb. 1 is really encouraging. Every experienced obstetrician knows the difficulties and fallacies in the evaluation of the advancement of pregnancy. These difficulties in the diagnosis of foetal maturity are sometimes even greater with overmaturity, a problem which was repeatedly discussed in recent issues of your journal 1-3 although from the therapeutic point of view only. The diagnosis of prolonged pregnancy is certainly as great a problem as its therapy.
Hartley’s critical analysis of the value of the appearance of epiphyseal calcifications for the diagnosis of the duration of pregnancy and the good results achieved by him in Manchester are reassuring. I should like to add one sign which for the past ten years has been very helpful in assessing fcetal maturity and overmaturity in our X-ray diagnosis laboratory. Fat tissue is accumulated only in the last weeks of foetal life and the subcutaneous tissue of premature foetus or newborn is almost devoid of fat coat. On X-ray pictures of premature pregnancies the subcutaneous fat-tissue shadow is usually easily discernible especially on the buttocks, the knees, and the elbows as a distinct subcutaneous shadow line of 1-3 mm. thickness. The presence of this sign allows for the diagnosis of a full-term foetus, with the one exception of a diabetic pregnancy where a giant foetus might show this symptom much earlier (where, anyhow, it might add to the indications of an earlier termination of pregnancy). In a prolonged pregnancy in which there is a deteriorating caloric supply through the degenerating, senescent placenta the foetus has to use up its own energy stocks-in the first place, its subcutaneous fat tissue. The disappearance of the subcutaneous fat-tissue shadow, especially if it was easily visible on a previous X-ray picture a week or two before, speaks for the diagnosis of a biologically prolonged pregnancy and for the necessity of a prompt termination of pregnancy, because of danger of anoxia and foetal distress.
If there has been no previous X-ray, as often happens, a large foetus with a fully developed and well-calcified skeleton but without a visible subcutaneous fat-tissue shadow is always suspect for overmaturity. A high standard of radiographic technique is essential. This sign must 1. 2. 3.
Gibberd, G. F. Lancet, Jan. 11, 1958, p. 64. Parker, R. B. ibid. Feb. 1, p. 265. Watson, P. S. ibid.
anaesthesia.
Very occasionally, the onset was related to operation performed under general anaesthesia and this must be mentioned even though it appears to destroy the force of my argument. However, some of these the involved lithotomy position. Since the operations number of operations performed under spinal anaesthesia has dropped this history has not been obtained. It was these cases, more than anything else, which caused me to prohibit the use of spinal anaesthetics for my patients. an
W. SAYLE-CREER.
Manchester.
INFANTILE GASTROENTERITIS
SIR,-Dr. Librach (Feb. 22) has made it abundantly plain that he does not believe in the pathogenicity of serotypes of Escherichia coli in infantile enteritis. Héemophilus infiuenzae, he says, was once held to be the cause of influenza, now known to be a virus disease; therefore, the laboratory has misled and hindered the clinician. He then implies that the laboratory work on the serology of Esch. coli has done a similar disservice to medicine by confusing rather than explaining the xtiology of infective enteritis in infants. He does not disclose his reasons for doubting all the work which has been published on the subject during the past 10 years. He has quoted a passage from a paper1 of which I was one of the authors. Lifted out of its context this quotation would suggest that the authors themselves doubted the significance of finding Esch. coli type 0.111 in infantile enteritis. This is not the case; the quoted passage does not represent the thesis of the paper in question, nor does it reflect the views of its authors at the time when it was written, much less so now.
City General Hospital, Stoke-on-Trent.
C. GILES.
SUDDEN DEAFNESS
SIR,-Mr. Boyes Korkis (Feb. 22) rightly stresses the need for treating patients with sudden perceptive deafness "as an absolute emergency ". He goes on to say that " a therapeutic trial of a stellate block would yield useful information and if carried out early enough would have a greater chance of success ". I can assure Mr. Korkis it not only would but does. Like Mr. Korkis, I do not advocate the use of intravenous nicotinic acid because I cannot see the advantage of this over a stellate block. Audiograms should be done immediately before the block and half an hour after under good conditions by a skilled technician in every case, and an efficient vasodilator drug-I use buphenine (’Perdilatal ’)-plays (not " could play ") an important part in maintaining the good effect of a successful stellate block. Mr. Korkis goes on to say that the old expectant attitude in sudden deafness of this type must change to one of action. I agree, but it must change similarly in the treatment of Meniere’s disease.2 Having done about 600 stellate blocks for inner-ear disorders during the past five years, under ideal audiometric conditions, having produced on many occasions a significant rise in hearing by stellate block, and having demonstrated by visual observation and lately by nystagmography the complete return of vestibular function after sympathetcomy, I am convinced that many cases of sudden deafness of percep1. 2.
Giles, C., Sangster, G. J. Hyg., Camb. 1948, 46, 1. Wilmot, T. J. Brit. med. J. 1957, ii, 1047.
tive
type-especially in young patients-have an aetiology essentially similar to that of Meniere’s disease, and that the new approach to these disorders, first demonstrated by Mr. E. Garnett Passe, has gone for too long without recognition. T. J. WILMOT. Tyrone County Hospital. SIR,-May
CLINICAL GERIATRICS I thank and commend you for your annota-
tion on this topic last week ? The special problems associated with the care of elderly patients are not known as well as they might be. The present medical curriculum gives students little teaching and less experience in this branch of medicine. In consequence, when they go into practice, they find themselves confronted with unfamiliar situations for which they have not been prepared by their teachers. Is it not time to press for more clinical instruction in geriatrics ? Surely the changes in our population make the care of elderly patients one of the most important tasks confronting our profession in this day and age. TREVOR H. HOWELL. London, S.W.16. SOFT-TISSUE RADIOGRAPHY IN ESTIMATING FŒTAL MATURITY AND POSTMATURITY
SiR,ŅYour leading article of Feb. 1 is really encouraging. Every experienced obstetrician knows the difficulties and fallacies in the evaluation of the advancement of pregnancy. These difficulties in the diagnosis of foetal maturity are sometimes even greater with overmaturity, a problem which was repeatedly discussed in recent issues of your journal 1-3 although from the therapeutic point of view only. The diagnosis of prolonged pregnancy is certainly as great a problem as its therapy.
Hartley’s critical analysis of the value of the appearance of epiphyseal calcifications for the diagnosis of the duration of pregnancy and the good results achieved by him in Manchester are reassuring. I should like to add one sign which for the past ten years has been very helpful in assessing fcetal maturity and overmaturity in our X-ray diagnosis laboratory. Fat tissue is accumulated only in the last weeks of foetal life and the subcutaneous tissue of premature foetus or newborn is almost devoid of fat coat. On X-ray pictures of premature pregnancies the subcutaneous fat-tissue shadow is usually easily discernible especially on the buttocks, the knees, and the elbows as a distinct subcutaneous shadow line of 1-3 mm. thickness. The presence of this sign allows for the diagnosis of a full-term foetus, with the one exception of a diabetic pregnancy where a giant foetus might show this symptom much earlier (where, anyhow, it might add to the indications of an earlier termination of pregnancy). In a prolonged pregnancy in which there is a deteriorating caloric supply through the degenerating, senescent placenta the foetus has to use up its own energy stocks-in the first place, its subcutaneous fat tissue. The disappearance of the subcutaneous fat-tissue shadow, especially if it was easily visible on a previous X-ray picture a week or two before, speaks for the diagnosis of a biologically prolonged pregnancy and for the necessity of a prompt termination of pregnancy, because of danger of anoxia and foetal distress.
If there has been no previous X-ray, as often happens, a large foetus with a fully developed and well-calcified skeleton but without a visible subcutaneous fat-tissue shadow is always suspect for overmaturity. A high standard of radiographic technique is essential. This sign must 1. 2. 3.
Gibberd, G. F. Lancet, Jan. 11, 1958, p. 64. Parker, R. B. ibid. Feb. 1, p. 265. Watson, P. S. ibid.