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NASAL SINUSITIS IN CHILDHOOD
170 " Decline and Fall " presents useful pabulum for a train journey, far better than most novels provided always that the reader has not already read it, as so many have done, when too young fully to appreciate the charm. I read Gibbon’s " Decline and Fall" for the first time in trains, and it took quite a long time. I am now engaged on Grote’s " History of Greece " which has not quite the same attractions and will take longer, in fact it seems possible that when death overtakes me, Grote’s History will still be unfinished. The secret of enjoyment of such reading is never to read for instruction, never to regard the reading as a lesson, never to attempt to remember, but to read purely for amusement and recreation. Novels and films show us life as it might be but certainly is not, history presents life as it was and still very much is. Gibbon is not the only work commended ; there are English histories, French histories, and period histories. Then a similar field is covered by biographies which may give an interesting high-power view of some special time or place. A knowledge of human nature is of the highest importance to any doctor, and his life’s work presents
constant opportunities for but to know human nature history may assist. *
his knowledge, lifetime is not enough;
expanding one
*
*
attracts many devotees ; it used to and many pilgrimages have I made to old buildings and well-known churches, but to-day the taste has passed, as tastes will sometimes, possibly the result of too many archaeological excursions. The study has its limitations and has not the attraction of natural history, but it is interesting to form conceptions of the habits and life of our ancestors disclosed by a study of their buildings and remains. The past deserves respect and may provide lessons and examples useful to-day, but if the sixteenth century had been solely devoted to the past we should have missed many of the renaissance productions which receive homage to-day, and should still be admiring rush-covered floors and the rather clumsy architecture of the Dark Ages. Perhaps teamwork here, as in medicine, is best. Those who feel so impelled will produce for us new forms of art and architecture while the archaeologists criticise these from their knowledge of the past.
Archseology
attract
me
CORRESPONDENCE INFECTION AND DISINFECTION
To the Editor
of
THE LANCET
SIR,-The lecture by Sir Weldon Dalrymplein your issue of Jan. 9th will be read with interest by practitioners other than medical officers of health and should appeal to the educated layman. I should like to refer to three
Champneys reproduced
points. First, whooping-cough. If it is true that the patient has already ceased to be infectious by the time the " whoop " appears, then many young prisoners may be liberated safely and much domestic inconvenience ended. We all know that the whoop may persist long after infection has disappeared, but experience (apparently fallacious) has suggested that the early convalescent may be a source of infection. Moreover, if this be correct, our present efforts at prevention are futile. The inclusion of infectious disease blocks in general hospitals is not peculiar to Scandinavia. It has long been the practice in our naval hospitals without, far as I know, any untoward results. Doubtless it would have been adopted more widely were it not for the fact that local authorities provide for infectious disease and, for the most part, voluntary bodies for other sickness. Nevertheless the idea is valuable on the grounds that small isolation hospitals are usually uneconomical and inefficient, and that unduly long journeys are not in the interest of the patient even under modern transport conditions. Lastly current and terminal disinfection. There is no doubt that " a good spring cleaning " is all that is necessary in most diseases when the patient has been treated at home throughout his illness, but I suggest that the full ritual is desirable in the case of diphtheria patients removed to hospital while still highly infectious, and when any infectious disease In scarlet occurs in a boarding house or hotel. fever practice varies. Admitting that infection in this disease is mainly personal to the sufferer, undetected cases and carriers, there still remains so
sufficient evidence in the opinion of many to full disinfection. I am, Sir, yours faithfully, G. B. PAGE,
justify
Medical Officer of Health, Exeter. Public Health Department, Exeter, Jan. 11th.
NASAL SINUSITIS IN CHILDHOOD
To the Editor
of
THE LANCET
SiR,—Your leader on this subject draws attention to a common malady but one not very familiar to those in charge of young children and school-children, judging from the regular stream of cases referred to hospital for removal of tonsils and adenoids, when the underlying condition is a nasal sinusitis. Complete nasal obstruction in infants and children is most commonly associated with a nasal discharge due to a sinusitis, which is also a fertile cause of a recurrent otitis, chronic cough, and relapsing chest conditions. A large mass of adenoids produces only intermittent nasal obstruction. In my experience the mucoid nasal discharge arises more frequently from the ethmoidal cells than from the antra. Cases of nasal sinusitis may often be recognised by the presence of nodules of lymphoid tissue scat. tered on the posterior pharyngeal wall, visible below the level of the uvula. A blob of mucus depends from the post-nasal space, coming into view when the child gags. In the presence of these signs, a cure of the nasal symptoms cannot be obtained by removal of tonsils and adenoids. The incidence of " clinical" nasal sinusitis is certainly more common than is realised, but percentages are deceptive. Anyone interested in the subject-especially if he is known to have some " new " treatment-soon becomes inundated with cases that are referred from all quarters, with the result that an exaggerated idea is obtained as to its real prevalence. In the last five years at the Queen’s Hospital for Children I have made it a routine to wash out the antra in all cases with a nasal discharge. I can only recollect some half a dozen cases in which pus was washed out of the antrum. (I exclude cases of
171
complications such as orbital an acute pan-sinusitis.)
cellulitis
secondary
to
Most of the antra must have contained only mucus, or have been empty, as the wash-outs were returned clear, in ’spite of the X ray disclosing antra which were completely opaque. This opacity must therefore indicate a thickened lining membrane only. I have never observed a fluid level in the antra of children. On a few occasions in the past, on clinical and radiological grounds, I have explored the antrum through the canine fossa, and have been disappointed by the small amount of disease disclosed-merely a slight thickening of the mucous lining of the antrum with no fluid visible. The discharge must therefore have had its origin in the ethmoidal region. A difficult problem arises in considering the treatment of the chronic cases-and many become so in spite of all types of treatment. All my patients are treated as a routine with a course of nasal lavage and displacement, which is performed as follows. The child lies down with the head well extended over the edge of the pillow, so that a line through the tip of the nose and the auditory meatus is vertical. While the child chants "K," "K" continuously, a solution of normal saline (with 2 grain of ephedrine hydrochloride added to ! pint) is slowly dropped from a rubber bulb syringe into one nostril, while a nozzle attached to a suction apparatus applied to the other nostril draws the fluid away. In this way the nasal chambers are thoroughly flushed with the solution, and all adherent and tenacious secretions removed. The ephedrine shrinks up the nasal mucosa and facilitates drainage from all the sinuses. The symptomatic relief is instantaneous and impressive. About 4-6 oz. of solution is used for each nostril. The treatment is repeated 2-3 times weekly for six weeks. At the end of each seance, 20 c.cm. of solution are dropped into the nose slowly. One nostril is blocked with the finger, while intermittent suction is applied " through the other nostril-to displace the solution into the sinuses. The child’s cooperation is essential. I have used this treatment for the last four years and the results on the whole have been gratifying in the acute and subacute cases. The chronic cases derive considerable benefit, but tend to relapse when the treatment ceases. If the symptoms are not relieved, antral lavage is practised under anaesthesia and the nasal displacement repeated subsequently. I have been disappointed with the results of antral drainage, and only after much consideration do I perform an inferior intranasal antrostomy, as I consider many of these cases to be ethmoidal and not antral in origin. I am, Sir, yours faithfully, N. ASHERSON.
watery
"
PURIFIED LIVER EXTRACTS
To the Editor
your
of
THE LANCET
issue of Dec. 26th last Dr. C. C. describes the trial in pernicious anaemia of a preparation said to be a "further purification of Dakin and West’s liver fraction." He states that the further purification has been obtained by applying the process described by us in the Acta Medica Scandinavica. The method described in his article, however, as used for this " further purification " consisted in applying only one part of our method to anahsemin, the original Dakin and West liver fraction.
SIR,-In
Ungley
In terms of the still unisolated anti-anaemic " pure examined by Dr. Ungley must be a relatively crude one. By our method of adsorp-
factor," the product tion
on
charcoal and selective elution with
water and
phenol
we
have
phenolconsistently prepared
direct from liver active material in very high concentration. In terms of the " total solids " present, the potency is considerably higher than that of Dr. Ungley’s preparation. We maintain, however, that a mere statement of the total solid content of a liver extract is, in the present state of our knowledge, likely to be very misleading ; in our opinion, writing as chemists,itmay involve clinicians in serious fallacies. Our investigations indicate that the Dakin and West method leads to inconsistent results and that it also involves a considerable loss of the antianaemic factor. By adsorption on charcoal and selective elution with phenol-solutions we obtained active material at a high concentration ; we also found that our process gave rise to a product of remarkably constant clinical activity. By repeating the process of adsorption and elution, followed by other methods of purification not yet published in detail, further concentration of the haemopoietic factor could be obtained. This is shown by the fact that we prepared material of such potency that 0’7 mg. produced a high reticulocyte response in the hands of Strandell, Poulsson, and Schartum-Hansen. We wish, however, to insist that even after this degree of purification we had not obtained the chemically pure factor. It is probable that at least two-thirds of our richest material consisted of inert matter. At the present time, therefore, we consider it is undesirable to state the dosage of a parenteral liver extract in terms of total solids, since inert substances must constitute a large proportion of the product, unless we push the purification to an advanced and uneconomical stage. If we assume that the amount of pure factor in a dose weighs 0-5 mg. (which is to be much too high) the statement that likely " 25 mg. of solids gave a maximal response " shows the dose to contain 98 per cent. of inert matter and 2 per cent. of the active factor. We agree, of course, that a low total solid content is desirable, but not that this gives a standard by which we can estimate dosage. We can produce from a given quantity of fresh liver a product of unvarying potency with a very low total solid content by stopping our process at a given stage, but the actual weight of the dose may vary by 50 or even 100 per cent. On the manufacturing scale, the proper objective must be to produce in the highest practicable degree of purity an anti-ansemic preparation of unvarying potency. Dr. Lester Smith, of the Glaxo Laboratories, Greenford, England, working in conjunction with us, has now been able by this method to make such a preparation, in which is produced from 100 grammes of fresh liver a fraction having an average weight of about 10 mg. The material is dissolved in 2 c.cm.-i.e., at a concentration of about 5 mg. per c.cm. A maximal reticulocyte response occurs after the injection of a quantity o,f material produced from 100 g., or at the most 200 g., of fresh liver, with a corresponding rise in the red blood corpuscles. This product, as is clear from its small weight, is of a high degree of concentration, but it is our earnest hope that the dose will not be stated in terms of its weight. At the present time we rely upon the standardised method of manufacture and the constant potency that has been found clinically. Expression of activity in terms of the weight of original fresh liver has a useful meaning only in such an instance.
constant opportunities for but to know human nature history may assist. *
his knowledge, lifetime is not enough;
expanding one
*
*
attracts many devotees ; it used to and many pilgrimages have I made to old buildings and well-known churches, but to-day the taste has passed, as tastes will sometimes, possibly the result of too many archaeological excursions. The study has its limitations and has not the attraction of natural history, but it is interesting to form conceptions of the habits and life of our ancestors disclosed by a study of their buildings and remains. The past deserves respect and may provide lessons and examples useful to-day, but if the sixteenth century had been solely devoted to the past we should have missed many of the renaissance productions which receive homage to-day, and should still be admiring rush-covered floors and the rather clumsy architecture of the Dark Ages. Perhaps teamwork here, as in medicine, is best. Those who feel so impelled will produce for us new forms of art and architecture while the archaeologists criticise these from their knowledge of the past.
Archseology
attract
me
CORRESPONDENCE INFECTION AND DISINFECTION
To the Editor
of
THE LANCET
SIR,-The lecture by Sir Weldon Dalrymplein your issue of Jan. 9th will be read with interest by practitioners other than medical officers of health and should appeal to the educated layman. I should like to refer to three
Champneys reproduced
points. First, whooping-cough. If it is true that the patient has already ceased to be infectious by the time the " whoop " appears, then many young prisoners may be liberated safely and much domestic inconvenience ended. We all know that the whoop may persist long after infection has disappeared, but experience (apparently fallacious) has suggested that the early convalescent may be a source of infection. Moreover, if this be correct, our present efforts at prevention are futile. The inclusion of infectious disease blocks in general hospitals is not peculiar to Scandinavia. It has long been the practice in our naval hospitals without, far as I know, any untoward results. Doubtless it would have been adopted more widely were it not for the fact that local authorities provide for infectious disease and, for the most part, voluntary bodies for other sickness. Nevertheless the idea is valuable on the grounds that small isolation hospitals are usually uneconomical and inefficient, and that unduly long journeys are not in the interest of the patient even under modern transport conditions. Lastly current and terminal disinfection. There is no doubt that " a good spring cleaning " is all that is necessary in most diseases when the patient has been treated at home throughout his illness, but I suggest that the full ritual is desirable in the case of diphtheria patients removed to hospital while still highly infectious, and when any infectious disease In scarlet occurs in a boarding house or hotel. fever practice varies. Admitting that infection in this disease is mainly personal to the sufferer, undetected cases and carriers, there still remains so
sufficient evidence in the opinion of many to full disinfection. I am, Sir, yours faithfully, G. B. PAGE,
justify
Medical Officer of Health, Exeter. Public Health Department, Exeter, Jan. 11th.
NASAL SINUSITIS IN CHILDHOOD
To the Editor
of
THE LANCET
SiR,—Your leader on this subject draws attention to a common malady but one not very familiar to those in charge of young children and school-children, judging from the regular stream of cases referred to hospital for removal of tonsils and adenoids, when the underlying condition is a nasal sinusitis. Complete nasal obstruction in infants and children is most commonly associated with a nasal discharge due to a sinusitis, which is also a fertile cause of a recurrent otitis, chronic cough, and relapsing chest conditions. A large mass of adenoids produces only intermittent nasal obstruction. In my experience the mucoid nasal discharge arises more frequently from the ethmoidal cells than from the antra. Cases of nasal sinusitis may often be recognised by the presence of nodules of lymphoid tissue scat. tered on the posterior pharyngeal wall, visible below the level of the uvula. A blob of mucus depends from the post-nasal space, coming into view when the child gags. In the presence of these signs, a cure of the nasal symptoms cannot be obtained by removal of tonsils and adenoids. The incidence of " clinical" nasal sinusitis is certainly more common than is realised, but percentages are deceptive. Anyone interested in the subject-especially if he is known to have some " new " treatment-soon becomes inundated with cases that are referred from all quarters, with the result that an exaggerated idea is obtained as to its real prevalence. In the last five years at the Queen’s Hospital for Children I have made it a routine to wash out the antra in all cases with a nasal discharge. I can only recollect some half a dozen cases in which pus was washed out of the antrum. (I exclude cases of
171
complications such as orbital an acute pan-sinusitis.)
cellulitis
secondary
to
Most of the antra must have contained only mucus, or have been empty, as the wash-outs were returned clear, in ’spite of the X ray disclosing antra which were completely opaque. This opacity must therefore indicate a thickened lining membrane only. I have never observed a fluid level in the antra of children. On a few occasions in the past, on clinical and radiological grounds, I have explored the antrum through the canine fossa, and have been disappointed by the small amount of disease disclosed-merely a slight thickening of the mucous lining of the antrum with no fluid visible. The discharge must therefore have had its origin in the ethmoidal region. A difficult problem arises in considering the treatment of the chronic cases-and many become so in spite of all types of treatment. All my patients are treated as a routine with a course of nasal lavage and displacement, which is performed as follows. The child lies down with the head well extended over the edge of the pillow, so that a line through the tip of the nose and the auditory meatus is vertical. While the child chants "K," "K" continuously, a solution of normal saline (with 2 grain of ephedrine hydrochloride added to ! pint) is slowly dropped from a rubber bulb syringe into one nostril, while a nozzle attached to a suction apparatus applied to the other nostril draws the fluid away. In this way the nasal chambers are thoroughly flushed with the solution, and all adherent and tenacious secretions removed. The ephedrine shrinks up the nasal mucosa and facilitates drainage from all the sinuses. The symptomatic relief is instantaneous and impressive. About 4-6 oz. of solution is used for each nostril. The treatment is repeated 2-3 times weekly for six weeks. At the end of each seance, 20 c.cm. of solution are dropped into the nose slowly. One nostril is blocked with the finger, while intermittent suction is applied " through the other nostril-to displace the solution into the sinuses. The child’s cooperation is essential. I have used this treatment for the last four years and the results on the whole have been gratifying in the acute and subacute cases. The chronic cases derive considerable benefit, but tend to relapse when the treatment ceases. If the symptoms are not relieved, antral lavage is practised under anaesthesia and the nasal displacement repeated subsequently. I have been disappointed with the results of antral drainage, and only after much consideration do I perform an inferior intranasal antrostomy, as I consider many of these cases to be ethmoidal and not antral in origin. I am, Sir, yours faithfully, N. ASHERSON.
watery
"
PURIFIED LIVER EXTRACTS
To the Editor
your
of
THE LANCET
issue of Dec. 26th last Dr. C. C. describes the trial in pernicious anaemia of a preparation said to be a "further purification of Dakin and West’s liver fraction." He states that the further purification has been obtained by applying the process described by us in the Acta Medica Scandinavica. The method described in his article, however, as used for this " further purification " consisted in applying only one part of our method to anahsemin, the original Dakin and West liver fraction.
SIR,-In
Ungley
In terms of the still unisolated anti-anaemic " pure examined by Dr. Ungley must be a relatively crude one. By our method of adsorp-
factor," the product tion
on
charcoal and selective elution with
water and
phenol
we
have
phenolconsistently prepared
direct from liver active material in very high concentration. In terms of the " total solids " present, the potency is considerably higher than that of Dr. Ungley’s preparation. We maintain, however, that a mere statement of the total solid content of a liver extract is, in the present state of our knowledge, likely to be very misleading ; in our opinion, writing as chemists,itmay involve clinicians in serious fallacies. Our investigations indicate that the Dakin and West method leads to inconsistent results and that it also involves a considerable loss of the antianaemic factor. By adsorption on charcoal and selective elution with phenol-solutions we obtained active material at a high concentration ; we also found that our process gave rise to a product of remarkably constant clinical activity. By repeating the process of adsorption and elution, followed by other methods of purification not yet published in detail, further concentration of the haemopoietic factor could be obtained. This is shown by the fact that we prepared material of such potency that 0’7 mg. produced a high reticulocyte response in the hands of Strandell, Poulsson, and Schartum-Hansen. We wish, however, to insist that even after this degree of purification we had not obtained the chemically pure factor. It is probable that at least two-thirds of our richest material consisted of inert matter. At the present time, therefore, we consider it is undesirable to state the dosage of a parenteral liver extract in terms of total solids, since inert substances must constitute a large proportion of the product, unless we push the purification to an advanced and uneconomical stage. If we assume that the amount of pure factor in a dose weighs 0-5 mg. (which is to be much too high) the statement that likely " 25 mg. of solids gave a maximal response " shows the dose to contain 98 per cent. of inert matter and 2 per cent. of the active factor. We agree, of course, that a low total solid content is desirable, but not that this gives a standard by which we can estimate dosage. We can produce from a given quantity of fresh liver a product of unvarying potency with a very low total solid content by stopping our process at a given stage, but the actual weight of the dose may vary by 50 or even 100 per cent. On the manufacturing scale, the proper objective must be to produce in the highest practicable degree of purity an anti-ansemic preparation of unvarying potency. Dr. Lester Smith, of the Glaxo Laboratories, Greenford, England, working in conjunction with us, has now been able by this method to make such a preparation, in which is produced from 100 grammes of fresh liver a fraction having an average weight of about 10 mg. The material is dissolved in 2 c.cm.-i.e., at a concentration of about 5 mg. per c.cm. A maximal reticulocyte response occurs after the injection of a quantity o,f material produced from 100 g., or at the most 200 g., of fresh liver, with a corresponding rise in the red blood corpuscles. This product, as is clear from its small weight, is of a high degree of concentration, but it is our earnest hope that the dose will not be stated in terms of its weight. At the present time we rely upon the standardised method of manufacture and the constant potency that has been found clinically. Expression of activity in terms of the weight of original fresh liver has a useful meaning only in such an instance.