- Email: [email protected]
Response to “Veeder Editorial”
3 0 2 Correspondence
August
1961
On buttock injections T o the Editor: The paper by GilIis and French in the JOURNAL (26: 195, I961) is a timely warning about the danger to the sciatic nerve from improper injections into the buttock. One point needs emphasis. The site of any injection is not where the needle punctures the skin, but where its point is situated when the injection is made. The upper outer quadrant of the buttock contains plenty of gluteal muscle which is well suited for injection. If the direction of the needle is kept upward and outward from the site of the skin puncture, the injection will be made into the muscle below the iliac crest and above and behind the great trochanter of the fenmr. There is no possibility of reaching the sciatic nerve. Gillis and French recommend the lateral thigh muscles for the site of intramuscular injections. These muscles are covered by the dense and unyielding fascia lata. Any swelling or secondary reaction to the injection is compressed between the fascia and the bone and would be more painful than necessary. There is also more pressure on this area when the infant lies on his side; the area above the trochanter is protected by the bone which takes the weight of the body in the lateral position. T o abandon the buttock entirely for all injections would be something like giving up a drug because overdoses are poisonous. If emphasis is put on the direction of the needle and on the position of the point, the upper outer quadrant is the best and safest place for intramuscular injections.
son often is unable to guarantee both the site of skin puncture and the site of injection in the buttock of an uncooperative infant. Therefore, we would favor the utilization of an area where no opportunity to neural damage exists. As regards paragraph three, it is our observation that most infants prefer either the dorsal or ventral recumbent postures a n d few, if any, spend a significant period of time in the lateral recumbent posture. Thus we would be unable to accept Dr. Smith's criticism of postural amplification of pain if one administers injections in the lateral compartment of the thigh. In our opinion, postural amplification of pain when injections are administered in the buttock is much more significant. As regards paragraph four, we feel that the fullest awareness of reality rather than tradition should dictate our medical acts. JOSEPt-[ I-I. F R E N C H ,
M.D.
j Site of skin puncture
C H A R L E S t l E N D E E S M I T H ~ M.D.
Reply To the editor: We would concur with paragraph one. As regards paragraph two, we feel that a single per-
/ Fig. 1. Apparent length of needle foreshortened by its direction, forward as well as upward and outward.
Response to "Veeder Editorial" To the Editor: Dr. Veeder's editorial in the March issue of the JOURNAL poses two questions. The first, Is the use of drugs which combat injection
"morally" justified for patients with Mongolian idiocy? The second, Should we or should we not advise operation for correction of a cardiac defect in such patients?
Volume 59
Number 2
Correspondence
The answer to the first depends upon one's concept of what is "moral," his respect for human life at whatever level, The answer to the second question, happily, has no "moral," religious, or philosophic aspects. Dr. Veeder characterizes the "con" (let them die) group as made up of "those whose interests are rather in the humanitarian side of medicine and who have had to face the devastating influence of a Mongolian idiot on family life, on normal siblings, and on marital relationships." I submit that it is more humanitarian to attempt
3 03
to cure the cardiac defects in these patients than to withhold operation in the hope that they will die. Even those with severe defects may live for many years. Their cardiac disability accounts for a great portion of the attention which must be paid them. Surely it is easier for a family to care for a physically healthy defective than for a disabled one. Numbered among the most grateful patients in m y practice are some whose "worthless" children have become less a burden to the family as a result of cardiac operation. DANIEL
F. DOSVNING,
M.D.
Gamma gNbuEn
To the Editor: The paper "Chickenpox and Leukemia" (J. PEDIAT. 58: 729, 1961) deserves close study because of the author's belief, based on a study of 4 patients, in the usefulness of large doses of gamma globulin for the modification of chickenpOX.
I would like to support this concept because of an experience I had several years ago, when 4 interns within a 3 week period developed chickenpox (Canad. M. A. J. 77: 697, 1957). Two interns, who just previously had received moderately large doses of poliomyelitis immune globulin ( h u m a n ) - - S q u i b b , had unusually mild clinical courses. Of the 2 other interns, neither of whom had received gamma globulin, one died and the other ran the typical severe clinical course which is characteristic of young adults with chickenpox. This episode and subsequent observations lead me to comment on the need for emphasizing the importance of giving adequate increasing doses of gamma globulin for the modification of chickenpox (Am. Pract. & Digest Treat. 10: 436, 1959). In view of the scarcity in the literature of controlled studies on this subject and my conclusion in the above report that my observations were such as to warrant further investigation, I was pleased to see Dr. Pinkel's statement that further trial of gamma globulin seems worth while. GEORGE X. TRIMBLE, M.D. MEMORIAL HOSPITAL OF LONG BEACI-~, GALIFORNIA
To the Editor: The 1961 edition of the "Red Book" of the American Academy of Pediatrics distinguishes between the aduh and the child dose of gamma globulin for the first time in its recommendations for the prevention of infectious hepatitis. This amounts to 2 ~ times as much for adults as for children per pound of body weight. These recommendations resemble those of Krugman and co-workers (J. A. M. A. 174: 823, 1960) and do not take into account 10 years of satisfactory experience and published reports by many workers using the dose of 0.01 c.c. per pound of body weight first advocated by Stokes and colleagues 10 years ago. In the Krugman trials this dose did not show the satisfactory results of previous published reports. The lot of globulin used by him at this dosage was not tested at any other dosage level. When he employed a higher dosage in his next trial, the gamma globulin used was from a different commercial source. We firmly believe that 10 years of experience should not be abruptly discarded on the basis of a single clinical trial, and work now in progress shows that gamma globulin lots manufactured by the cold ethanol process developed by Cohn are quite uniform in potency. It is common knowledge that the antibodies in such material remain stable long beyond their dating period. The Krugman lot in question was not made by the Cohn method. To our knowledge this is true of no other commercial source of gamma globulin. We have had the experience of having had a different lot number from the same source
August
1961
On buttock injections T o the Editor: The paper by GilIis and French in the JOURNAL (26: 195, I961) is a timely warning about the danger to the sciatic nerve from improper injections into the buttock. One point needs emphasis. The site of any injection is not where the needle punctures the skin, but where its point is situated when the injection is made. The upper outer quadrant of the buttock contains plenty of gluteal muscle which is well suited for injection. If the direction of the needle is kept upward and outward from the site of the skin puncture, the injection will be made into the muscle below the iliac crest and above and behind the great trochanter of the fenmr. There is no possibility of reaching the sciatic nerve. Gillis and French recommend the lateral thigh muscles for the site of intramuscular injections. These muscles are covered by the dense and unyielding fascia lata. Any swelling or secondary reaction to the injection is compressed between the fascia and the bone and would be more painful than necessary. There is also more pressure on this area when the infant lies on his side; the area above the trochanter is protected by the bone which takes the weight of the body in the lateral position. T o abandon the buttock entirely for all injections would be something like giving up a drug because overdoses are poisonous. If emphasis is put on the direction of the needle and on the position of the point, the upper outer quadrant is the best and safest place for intramuscular injections.
son often is unable to guarantee both the site of skin puncture and the site of injection in the buttock of an uncooperative infant. Therefore, we would favor the utilization of an area where no opportunity to neural damage exists. As regards paragraph three, it is our observation that most infants prefer either the dorsal or ventral recumbent postures a n d few, if any, spend a significant period of time in the lateral recumbent posture. Thus we would be unable to accept Dr. Smith's criticism of postural amplification of pain if one administers injections in the lateral compartment of the thigh. In our opinion, postural amplification of pain when injections are administered in the buttock is much more significant. As regards paragraph four, we feel that the fullest awareness of reality rather than tradition should dictate our medical acts. JOSEPt-[ I-I. F R E N C H ,
M.D.
j Site of skin puncture
C H A R L E S t l E N D E E S M I T H ~ M.D.
Reply To the editor: We would concur with paragraph one. As regards paragraph two, we feel that a single per-
/ Fig. 1. Apparent length of needle foreshortened by its direction, forward as well as upward and outward.
Response to "Veeder Editorial" To the Editor: Dr. Veeder's editorial in the March issue of the JOURNAL poses two questions. The first, Is the use of drugs which combat injection
"morally" justified for patients with Mongolian idiocy? The second, Should we or should we not advise operation for correction of a cardiac defect in such patients?
Volume 59
Number 2
Correspondence
The answer to the first depends upon one's concept of what is "moral," his respect for human life at whatever level, The answer to the second question, happily, has no "moral," religious, or philosophic aspects. Dr. Veeder characterizes the "con" (let them die) group as made up of "those whose interests are rather in the humanitarian side of medicine and who have had to face the devastating influence of a Mongolian idiot on family life, on normal siblings, and on marital relationships." I submit that it is more humanitarian to attempt
3 03
to cure the cardiac defects in these patients than to withhold operation in the hope that they will die. Even those with severe defects may live for many years. Their cardiac disability accounts for a great portion of the attention which must be paid them. Surely it is easier for a family to care for a physically healthy defective than for a disabled one. Numbered among the most grateful patients in m y practice are some whose "worthless" children have become less a burden to the family as a result of cardiac operation. DANIEL
F. DOSVNING,
M.D.
Gamma gNbuEn
To the Editor: The paper "Chickenpox and Leukemia" (J. PEDIAT. 58: 729, 1961) deserves close study because of the author's belief, based on a study of 4 patients, in the usefulness of large doses of gamma globulin for the modification of chickenpOX.
I would like to support this concept because of an experience I had several years ago, when 4 interns within a 3 week period developed chickenpox (Canad. M. A. J. 77: 697, 1957). Two interns, who just previously had received moderately large doses of poliomyelitis immune globulin ( h u m a n ) - - S q u i b b , had unusually mild clinical courses. Of the 2 other interns, neither of whom had received gamma globulin, one died and the other ran the typical severe clinical course which is characteristic of young adults with chickenpox. This episode and subsequent observations lead me to comment on the need for emphasizing the importance of giving adequate increasing doses of gamma globulin for the modification of chickenpox (Am. Pract. & Digest Treat. 10: 436, 1959). In view of the scarcity in the literature of controlled studies on this subject and my conclusion in the above report that my observations were such as to warrant further investigation, I was pleased to see Dr. Pinkel's statement that further trial of gamma globulin seems worth while. GEORGE X. TRIMBLE, M.D. MEMORIAL HOSPITAL OF LONG BEACI-~, GALIFORNIA
To the Editor: The 1961 edition of the "Red Book" of the American Academy of Pediatrics distinguishes between the aduh and the child dose of gamma globulin for the first time in its recommendations for the prevention of infectious hepatitis. This amounts to 2 ~ times as much for adults as for children per pound of body weight. These recommendations resemble those of Krugman and co-workers (J. A. M. A. 174: 823, 1960) and do not take into account 10 years of satisfactory experience and published reports by many workers using the dose of 0.01 c.c. per pound of body weight first advocated by Stokes and colleagues 10 years ago. In the Krugman trials this dose did not show the satisfactory results of previous published reports. The lot of globulin used by him at this dosage was not tested at any other dosage level. When he employed a higher dosage in his next trial, the gamma globulin used was from a different commercial source. We firmly believe that 10 years of experience should not be abruptly discarded on the basis of a single clinical trial, and work now in progress shows that gamma globulin lots manufactured by the cold ethanol process developed by Cohn are quite uniform in potency. It is common knowledge that the antibodies in such material remain stable long beyond their dating period. The Krugman lot in question was not made by the Cohn method. To our knowledge this is true of no other commercial source of gamma globulin. We have had the experience of having had a different lot number from the same source