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RESISTANT STAPHYLOCOCCI
420
Letters
the Editor
to
RESISTANT STAPHYLOCOCCI have read with interest the reports by Rountree SIR,—I and Thomson1 and of Dr. Mary Barber and her associates2 concerning the parasitisation or infection of staff and patients in the Royal Prince Alfred Hospital, Sydney, and St. Thomas’s Hospital, London, with strains of
penicillin-resistant Staphylococcus aureus. I would judge from observations made in the United States that the incidence of penicillin-resistant strains of this organism in infections is definitely increasing. This poses a problem in therapy. While many of the penicillinresistant strains are sensitive to streptomycin, these may rapidly become resistant to this antibiotic in the course of therapy. Also, the treatment of serious infection with this latter antibiotic is not without risk from the rather frequent toxic reactions. Our experience has convinced us thatAureomycin ’ is a highly effective antibiotic agent in staphylococcal infection. Hitherto -its toxic effects, other than nausea, vomiting, and looseness of the bowels, have been minimal. Because of its effectiveness in relatively modest doses and its lack of toxicity, it is our belief that aureomycin is now the antibiotic of choice for the treatment of staphylococcal infection. I feel that physicians would do well to keep this point in mind, because only too frequently large amounts of penicillin are wasted in attempts to control a staphylococcal infection which would resbond promptly to therapy with aureomvcin. Department of Preventive Medicine, PERRIN H. LONG. The Johns Hopkins University, Baltimore.
TRICHLORETHYLENE IN OBSTETRICS
SIR,—Recently we witnessed one of the regularly recurring instances of lay interest in obstetrical analgesia. This coincided with correspondence in the medical press on the same subject ; and the matter was finally referred to a committee. Meanwhile it appears to me that there is a general impression that wehave but to await the invention of the perfect apparatus so that the midwife can administer trichlorethylene, instead of gas-and-air, and the problem of obstetrical analgesia will be finally solved. May I make a plea that gas-and-air shall not be too
readily discarded ?
When
properly administered, gas-and-air gives
a good greater part of the average labour. When it fails adequately to -cover the actual birth, it does’so for one or more of the following reasons : (a) the administration has not been thoroughly explained to the patient (the extent of success with gas-and-air is frequently in direct ratio to the attention given to its administration) ; (b) however well the administration is supervised, gas-and-air, per se, is not always adequate for this stage of labour ; (c) the strength of the analgesic agent has remained fixed while the strength of the pain stimuli has been steadily increasing, so that after some time the patient may acquire quite a fair degree of tolerance. What is the case for replacing this regime by the inhalation of a fixed concentration of trichlorethylene ? I believe that trichlorethylene is an outstandingly good analgesic for midwifery, its optimum usefulness being towards the end of the second stage when it frequently gives good relief where gas-and-air has failed to do so. But I also believe that it has two disadvantages. The first is that when it is given as the sole inhalational agent and at a constant strength, the patient can acquire, as
degree
in the it not
of
analgesia
case
of
for the
gas-and-air,
sufficient tolerance to render
quite adequate for the delivery. On the second disadvantage I speak with great caution. There are so many factors influencing the course of labour that it is
1. 2.
Rountree, P. M., Thomson, E. F. Lancet, 1949, ii, 501. Barber, M., Hayhoe, F. G. J., Whitehead, J. E. M. Ibid, p. 1120.
very difficult to judge accurately and justly the effects of one drug. Nevertheless I have gained the definite impression that where trichlorethylene has been inhaled over a long period, the uterine action sometimes tends to become increasingly sluggish. On the other hand, I have never had reason to regret reserving trichlorethylene for the last part of labour and then giving it in adequate
strength. Are we, then, going to gain much from this possible switch-over ? It has always seemed to me that we are rather optimistic to expect that the pains of the various phases of labour, varying as they do not only in intensity but also in nature and in the way in which they impinge on consciousness, shall be adequately covered by an unvarying concentration of one drug. Surely the answer lies in the correctly timed application of both of these valuable drugs. I would suggest as the ideal, that the patient delivered by a midwife should be given gas-and-air, starting as the first stage nears its end, and continued until the head is starting to pass over the perineum. Trichlorethylene should then be substituted, given by an inhaler the safety of which is determined by limitation of the total quantity of the drug as well as by constancy of concentration. Thus we should realise the advantages of each drug without incurring the shortcomings of either. Objections may be raised on two grounds : difficulty of transport, and lack of simplicity. The former has been largely answered by the introduction of light-weight cylinders : a portable model working on the jet-andventuri system, which I have found very satisfactory, weighs just on 20 lb. when fitted with a 100 gallon lightweight cylinder. As regards lack of simplicity, I feel that this disadvantage will be outweighed by the advantages to the patient. G. C. STEEL. London, W.8. _
INCIDENCE OF PEPTIC ULCER
SIR,—Substantial differences in the proportions of duodenal to gastric ulcer are being reported in perforation series from different parts of the country : for instance, 6 : 1 in Glasgow,! almost 9 : 1 in Newcastle,2and about 3 : 1 in London.3 There is no obvious explanation for these discrepancies, and so little is known of the causes of ulcer and its increase in recent years that noclue should be neglected. We are therefore following it up in a small investigation. The Ministry of Food have kindly agreed to send a communication from the Medical Research Council to the certifying doctor for each occasion on which priority milk and/or eggs were claimed on form R.G.50, class 1 (D), in Glasgow, Newcastle,. Willesden, and Acton during a period in December, 1949. This communication will contain an explanatory covering letter, a form for entering facts about the patient, such as sex, age, and situation of ulcer, and a stamped addressed envelope for its return to us. When the information is analysed ,it should be possible for the first time to work out rates for different types of ulcer in different areas of the country, and to know whether some areas have a particularly high or low incidence of gastric or duodenal ulcer. A serial-number system will be used whereby the confidential nature of medical information will be faithfully preserved. No names will pass from the doctors to us ; no information will be passed back by ourselves to the Ministry of Food. We have consulted the chairman of the central ethical committee of the British Medical Association, and he assures us that there can be no ethical objection to the completion of the, forms. ’
Illingworth, C. F. W., Scott, L. D. W., med. J. 1944, ii, 617, 655. 2. Houston, W. Ibid, 1946, ii, 221. 3. Jones, F. A., Parsons, P. J., White, B. 1.
Jamieson, R. A.
Ibid, Jan. 28,
Brit.
p. 211.
Letters
the Editor
to
RESISTANT STAPHYLOCOCCI have read with interest the reports by Rountree SIR,—I and Thomson1 and of Dr. Mary Barber and her associates2 concerning the parasitisation or infection of staff and patients in the Royal Prince Alfred Hospital, Sydney, and St. Thomas’s Hospital, London, with strains of
penicillin-resistant Staphylococcus aureus. I would judge from observations made in the United States that the incidence of penicillin-resistant strains of this organism in infections is definitely increasing. This poses a problem in therapy. While many of the penicillinresistant strains are sensitive to streptomycin, these may rapidly become resistant to this antibiotic in the course of therapy. Also, the treatment of serious infection with this latter antibiotic is not without risk from the rather frequent toxic reactions. Our experience has convinced us thatAureomycin ’ is a highly effective antibiotic agent in staphylococcal infection. Hitherto -its toxic effects, other than nausea, vomiting, and looseness of the bowels, have been minimal. Because of its effectiveness in relatively modest doses and its lack of toxicity, it is our belief that aureomycin is now the antibiotic of choice for the treatment of staphylococcal infection. I feel that physicians would do well to keep this point in mind, because only too frequently large amounts of penicillin are wasted in attempts to control a staphylococcal infection which would resbond promptly to therapy with aureomvcin. Department of Preventive Medicine, PERRIN H. LONG. The Johns Hopkins University, Baltimore.
TRICHLORETHYLENE IN OBSTETRICS
SIR,—Recently we witnessed one of the regularly recurring instances of lay interest in obstetrical analgesia. This coincided with correspondence in the medical press on the same subject ; and the matter was finally referred to a committee. Meanwhile it appears to me that there is a general impression that wehave but to await the invention of the perfect apparatus so that the midwife can administer trichlorethylene, instead of gas-and-air, and the problem of obstetrical analgesia will be finally solved. May I make a plea that gas-and-air shall not be too
readily discarded ?
When
properly administered, gas-and-air gives
a good greater part of the average labour. When it fails adequately to -cover the actual birth, it does’so for one or more of the following reasons : (a) the administration has not been thoroughly explained to the patient (the extent of success with gas-and-air is frequently in direct ratio to the attention given to its administration) ; (b) however well the administration is supervised, gas-and-air, per se, is not always adequate for this stage of labour ; (c) the strength of the analgesic agent has remained fixed while the strength of the pain stimuli has been steadily increasing, so that after some time the patient may acquire quite a fair degree of tolerance. What is the case for replacing this regime by the inhalation of a fixed concentration of trichlorethylene ? I believe that trichlorethylene is an outstandingly good analgesic for midwifery, its optimum usefulness being towards the end of the second stage when it frequently gives good relief where gas-and-air has failed to do so. But I also believe that it has two disadvantages. The first is that when it is given as the sole inhalational agent and at a constant strength, the patient can acquire, as
degree
in the it not
of
analgesia
case
of
for the
gas-and-air,
sufficient tolerance to render
quite adequate for the delivery. On the second disadvantage I speak with great caution. There are so many factors influencing the course of labour that it is
1. 2.
Rountree, P. M., Thomson, E. F. Lancet, 1949, ii, 501. Barber, M., Hayhoe, F. G. J., Whitehead, J. E. M. Ibid, p. 1120.
very difficult to judge accurately and justly the effects of one drug. Nevertheless I have gained the definite impression that where trichlorethylene has been inhaled over a long period, the uterine action sometimes tends to become increasingly sluggish. On the other hand, I have never had reason to regret reserving trichlorethylene for the last part of labour and then giving it in adequate
strength. Are we, then, going to gain much from this possible switch-over ? It has always seemed to me that we are rather optimistic to expect that the pains of the various phases of labour, varying as they do not only in intensity but also in nature and in the way in which they impinge on consciousness, shall be adequately covered by an unvarying concentration of one drug. Surely the answer lies in the correctly timed application of both of these valuable drugs. I would suggest as the ideal, that the patient delivered by a midwife should be given gas-and-air, starting as the first stage nears its end, and continued until the head is starting to pass over the perineum. Trichlorethylene should then be substituted, given by an inhaler the safety of which is determined by limitation of the total quantity of the drug as well as by constancy of concentration. Thus we should realise the advantages of each drug without incurring the shortcomings of either. Objections may be raised on two grounds : difficulty of transport, and lack of simplicity. The former has been largely answered by the introduction of light-weight cylinders : a portable model working on the jet-andventuri system, which I have found very satisfactory, weighs just on 20 lb. when fitted with a 100 gallon lightweight cylinder. As regards lack of simplicity, I feel that this disadvantage will be outweighed by the advantages to the patient. G. C. STEEL. London, W.8. _
INCIDENCE OF PEPTIC ULCER
SIR,—Substantial differences in the proportions of duodenal to gastric ulcer are being reported in perforation series from different parts of the country : for instance, 6 : 1 in Glasgow,! almost 9 : 1 in Newcastle,2and about 3 : 1 in London.3 There is no obvious explanation for these discrepancies, and so little is known of the causes of ulcer and its increase in recent years that noclue should be neglected. We are therefore following it up in a small investigation. The Ministry of Food have kindly agreed to send a communication from the Medical Research Council to the certifying doctor for each occasion on which priority milk and/or eggs were claimed on form R.G.50, class 1 (D), in Glasgow, Newcastle,. Willesden, and Acton during a period in December, 1949. This communication will contain an explanatory covering letter, a form for entering facts about the patient, such as sex, age, and situation of ulcer, and a stamped addressed envelope for its return to us. When the information is analysed ,it should be possible for the first time to work out rates for different types of ulcer in different areas of the country, and to know whether some areas have a particularly high or low incidence of gastric or duodenal ulcer. A serial-number system will be used whereby the confidential nature of medical information will be faithfully preserved. No names will pass from the doctors to us ; no information will be passed back by ourselves to the Ministry of Food. We have consulted the chairman of the central ethical committee of the British Medical Association, and he assures us that there can be no ethical objection to the completion of the, forms. ’
Illingworth, C. F. W., Scott, L. D. W., med. J. 1944, ii, 617, 655. 2. Houston, W. Ibid, 1946, ii, 221. 3. Jones, F. A., Parsons, P. J., White, B. 1.
Jamieson, R. A.
Ibid, Jan. 28,
Brit.
p. 211.