STEROIDS FOR ASTHMATIC CHILDREN

335 on erecting new, modern, and expensive hospital buildings or creating a network of preventive paediatrics cum treat-

spent

people, the choice But be the latter. one should hospital building looks obviously more impressive than 50 small centres, and to give in to the ment centres within easy reach of the

temptation is, alas,

very easy. Department of Pædiatrics,

Safdarjang Hospital, New Delhi.

SHANTI GHOSH.

TREATMENT OF TETANUS IN NEONATES SIR,-Brainstem intoxication as a cause of death in tetanus has been

while

not

emphasised recently.’ Experience in Cape Town, approaching the excellence of the results achieved at

Leeds,2 favours the view that the intoxication is reversible unless there is some additional factor, usually a severe asphyxial episode. With improved techniques fewer deaths are attributed to intoxication. Some recent changes in the treatment of neonatal tetanus by total relaxation and intermittent positivepressure respiration (I.P.P.R.) are perhaps worth recording, because they may help in the care of any infant requiring a tracheostomy. In the past, despite emphasis on an aseptic technique, infection via the tracheostomy and pneumonia have been a constant source of trouble and the commonest cause of death. This has been strikingly reduced by instilling 0.25 ml. of a mixture of penicillin and colistin (500 units of each per ml. in distilled water freshly prepared each day) down the tracheotomy tube every six hours, only when and for as long as secretions are purulent. Rarely, other antibiotics have been instilled if indicated by the sensitivity of the organism isolated. Routine antibiotics are given as well. Since starting this regimen there has been only 1 death from pneumonia (giant-celled pneumonia) in 40 consecutive cases. Complications of tracheostomy have been lessened by ensuring that the tracheotomy tube does not press unduly on the wall of the trachea to cause ulceration. A size-18 biliary catheter T-tube connecting the tracheotomy tube to the respirator makes for flexibility and reduces the pressure transmitted on to the tracheotomy tube by the attachment to the respirator. The tapes holding the tracheotomy tube are now tied more loosely, so that the tube can be mobilised and pulled out for about 0-6 cm. (1/4 in.), and does not become immobilised in one position. Since adopting, with modifications, the technique described by Davenport,3 and with help from the anaesthetists, detubation has become almost routine. If an infant will not tolerate occlusion of a 3 mm. tracheotomy tube in situ, a ’Portex ’ plastic nasotracheal tube (3-0 mm. diameter) is passed under general anaesthesia. This pushes any granulations which may have formed in the trachea above the tracheostomy down into the fistula, through which they can be seen with an auriscope and extracted with forceps. If much granulation tissue is removed, the nasotracheal tube is withdrawn, the tracheotomy tube reinserted, and a further trial made with occlusion two days later. Otherwise, when the nasotracheal tube can be seen at the bottom of the tracheostomy fistula clear of any overlying granulations, the tube is left in situ with the tip reaching to just below the level of the tracheostomy. It is secured by strapping which encircles the head and grips the tube firmly as it emerges from the nose. A stomach tube is passed through the other nostril for feeding. Subsequently the infant is nursed in a well-humidified atmosphere. Antibiotics are given but not steroids. Instillation of the penicillin-colistin mixture down the tube has been added. After four days the tube is removed in the operating-theatre by the anaesthetist. In 13 out of 15 cases this has been successful, probably because the endotracheal tube elevates buckled tracheal rings and straightens out any angulation of the trachea.4 In 2 of the early cases the tube had to be Adams, E. B., Holloway, R., Thambiran, A. K., Desai, S. D. Lancet, 1966, ii, 1176; Montgomery, R. D. ibid. p. 1420. 2. Garland, H. ibid. p. 546. 3. Davenport, H. T. Can. med. Ass. J. 1964, 91, 1074. 4. Smythe, P. M. J. Pediat. 1964, 65, 446. 1.

reinserted.

1 of these infants

died; a subglottic stenosis had because too large an endotracheal tube The other was detubated successfully at the

developed, probably

had been used. second attempt. The average duration of tracheostomy in the last 31 cases has been eight weeks, the longest twelve weeks. Previously 10 out of 39 infants took longer than twelve weeks before detubation was achieved. Although our overall neonatal mortality is 37% with these recent changes in treatment, there have been 9 deaths (22%) in the last 40 cases. The major cause of death is no longer infection. At least 3 deaths from mechanical failures were preventable. 2 infants " collapsed " with cardiac arrest; these cases were thought to result from asphyxia due to ineffective suctioning rather than brainstem intoxication, because in each instance collapse occurred at night when nurses new to the unit were in charge, in infants who when last seen were perfectly well, and who after resuscitation survived in a decerebrate state for weeks. The remaining 4 infants died of: giant-celled pneumonia; tracheal stenosis; jaundice with umbilical sepsis; and obstruction of the large bowel from inspissated milk-an excess of d-tubocurarine and feeds made from dried milk powder instead of the usual evaporated milk probably contributed to this case. Neonatal tetanus should be prevented by immunisation of the pregnant mother, but until this is achieved it seems a pity that in your annotation5 the cost and difficulties of treatment with I.P.P .R. are emphasised, since this discourages centres being developed where they are required. The cost of equipment is not high, and with 2 nurse-aides to a 6-bed unit, which at times has had as many as 5 infants on respirators at the same time, over 100 neonates have been successfully treated in Cape Town. Most of the’difficulties in treatment seem to have been overcome, and the results are largely determined by the care given by nurses, and the amount of time spent by the registrars in ensuring that tracheobronchial secretions are

efficiently aspirated. Red Cross War Memorial Children’s Rondebosch, Cape Town.

Hospital,

P. M. SMYTHE.

STEROIDS FOR ASTHMATIC CHILDREN SIR,-The article by Dr. Jacoby s may influence paediatricians who do not yet appreciate how often the evils of chronic asthma are greater than those of intelligent steroid therapy, the complications of which attract more attention than the effects. The relief obtained is such that on humanitarian grounds alone it is incomprehensible why steroids are used with such reluctance. It is illogical that while diabetics inject themselves with insulin, asthmatics seldom regulate their steroids. Adequate dosage early in an attack avoids unnecessary hospital admissions, with consequent psychological and physical trauma.

That allergy as a cause of asthma is not mentioned by Dr. Jacoby is surprising, for to write so convincingly on treatment whilst ignoring possible causes seems a most regrettable omission. Perhaps some children were subjected to needless steroid therapy for asthma caused by some easily removable allergen such as pets, feather-bedding, or a food. The logical approach is to use steroids as a means of control while seeking the cause of the condition, but only as a crutch soon to be discarded. The later disillusion of many physicians originally interested in allergy has been mainly due to relying on skin tests without realising their fallibility. Extensive history-taking is the basis of diagnosis, particularly in allergy, but until one knows the essential questions the answers will not be obtained. I have used nasal provocation tests diagnostically for six years, and for testing after treatment to determine its effectiveness, so that objectivity becomes possible. The use of simple elimination diets revealed that 50 out of 200 " intrinsic " asthmatics were food-sensitive, particularly to milk and baker’s yeast. 5. 6.

Lancet, 1966, ii, 482. Jacoby, N. M. ibid. p. 1354.

336

Neglect of allergy as a specialty in this country is undoubtedly due

lack of interest because of poor treatment results, but recent advances in immunology could stimulate young physicians to enter this field with as much enthusiasm as colleagues in the United States. Allergists observe the chronic asthmatic through all the seven ages, because for them there is no demarcation between childhood and adolescence, with transfer to another consultant at a crucial period in the patient’s life. Dr. Jacoby’s approach to the problem of the asthmatic child is enlightened, but in ignoring allergic factors there is the potential danger that some children will become unnecessarily steroid-dependent. One is thankful for the means to give relief, but magic formulas for quick, easy cures remain as elusive as

tion of dietary sugar and total calories. Apart from the diet it is quite possible, and even likely, that the treated group are more highly motivated than the control group to reduce weight, take more exercise, and alter their smoking habits. The construction and running of one of these large trials cannot, of course, be beyond criticism, but at the same time caution must be exercised in the evaluation of the results. A. J. SALTER Basle, Switzerland.

to

ever.

H. MORROW BROWN.

VINCA ALKALOIDS AND SALIVARY-GLAND PAIN SiR,—The combination of salivary-gland pain and severe constipation was not uncommon in patients treated with

pempidine hydrogen

tartrate

(’Tenormal’, ’Perolysen’)

at a

time when the absence of other effective hypotensive drugs required its use in high dosage. Distension of the salivary glands was not found in these patients-indeed, salivary secretion was reduced. The similar and unusual combination of symptoms described by Dr. Rose (Jan. 28, p. 213) in patients treated with vinca alkaloids makes a ganglion-blockade effect

tempting explanation. The constipation of pempidine-induced ganglion blockade resembles that resulting from other similar agents. It is at least partly due to decreased intestinal motility, as described by Goldstone1 in a patient receiving pentamethonium, whose condition of abdominal pain, vomiting, distension, and constipation mimicked acute intestinal obstruction so closely that laparotomy was undertaken. The small gut was principally a

affected. The outcome was fatal. If a ganglion-blockade effect is the correct explanation in the case of vinca alkaloids too, then, while laxatives clearly have a place, the use of neostigmine might be considered if distension has developed. I wonder whether guanethidine relieved the symptoms, as it sometimes did when they were due to

pempidine. Royal Free Hospital, Gray’s Inn Road, London W.C.1.

ANTHONY G. WHITE.

PROPRANOLOL IN MYOCARDIAL INFARCTION SIR,-Dr. Smith (Jan. 21, p. 165) has misread our letter.2 We do not use propranolol routinely in acute myocardial infarction. Our reason for writing was to indicate that the complication of recurrent ventricular fibrillation may be amenable to treatment with propranolol, in a dosage onetenth of that recommended by Sloman et awl.3 H. IKRAM Charing Cross Hospital, P. G. F. NIXON. London W.C.2.

THE ANTI-CORONARY CLUB SiR,—Ishould like to comment on your annotation (Jan. 21,

p. 148). It is certainly very important that a group such as the Anticoronary Club has produced a significant reduction in mortality from coronary heart-disease, but it should not be assumed, however, that this reduction in mortality is necessarily the result of a change in the polyunsaturated saturated fat ratio in the diet. The findings of the Club do not help to make the question of aetiology any less controversial than before, for if their diet is carefully studied it will be seen that there is a reduc1. Goldstone, B. S. Afr. med. J. 1952, 26, 552. 2. Ikram, H., Nixon, P. G. F. Lancet, 1966, ii, 1134. 3. Sloman, G. J., Robinson, J. S., Mclean, K. H. Br. med. J. 1965, i, 895.

UTERINE CANCER in your annotation,’ We have three remark SIR,-The Women and Oriental in of Occidental Jewish groups (i.e., with similar very low Israel, as well as New York City] incidence-rates for cervical cancer, yet showing very wide differences in the only factors that have seemed to be positively associated with cervical cancer", calls for a number of reservations. The comprehensive report by Stewart et al.,2 the basis for your statement, has one major drawback: its classification of all Israeli Jews coming from Asia and Africa, together with the "

...

"

Sephardi Jews, as being " Sephardi-Oriental Jews as opposed to Ashkenazi Jews-those of European origin-is rather mechanical. The Jewish communities in the different Islamic countries, of which the largest were in Yemen, Iraq, and North Africa, were isolated from each other for many centuries, and differ strikingly both genetically and culturally. For example, glucose-6-phosphate-dehydrogenase deficiency is highly prevalent in Iraq, but less so in Yemenite Jews (5:1), and much less in Jews from North Africa (20:1).3 The frequency of various forms of cancer, such as of stomachand cesophagus,l differs between these groups as well. Thus, even the grouping by continent of origin such as Asia and Africa is unsatisfactory, and distinction should be made by country of exile-i.e., Yemen, Babylon (Iraq, Iran, and Kurdistan), North Africa, and Eastern and Central Europe (Ashkenazis). Evidence collected so far points to the fact that this is probably true for cancer of the cervix as well. Preliminary "

"

evaluation of the rates6 for the past 5 years indicates that agecancer of Israeli women born in North Africa is about twice as high as in women born in Rumania and more than three times as high as in those born in Russia, Poland, and Germany. These figures confirm former clinical impressions in our hospital that cancer of the cervix is more prevalent among women coming from North Africa than in the European group and in other, though non-Ashkenazi, groups like the Yemenites. Consequently by grouping the Yemenites with a low incidence and the Iraqui Jews with a medium one into one " Sephardi-Oriental " conglomerate, as is done by Stewart et al., these differences would obviously cancel each other out. A more detailed evaluation of this problem is now in progress. Thus, your query whether " Jewish women are partly protected from cervical cancer " and your conclusion that " all the obvious leads seem to have petered out " are not supported. On the contrary, we have at hand several groups of Jewish women who differ widely in both incidence of cervical cancer and marital history and habits. These observations, as well as the recent data of Martin and Lilienfeld7 on coital factors in cervical cancer among Jewish women, may provide an excellent opportunity for the evaluation of associated attributes. BARUCH MODAN MICHAELA MODAN Tel Hashomer Government Hospital, CHAIM SHEBA. Israel.

adjusted incidence of cervical

1. 2. 3. 4. 5. 6. 7.

Lancet, 1966, ii, 1453. Stewart, H. L., Dunham, L. J., Casper, J., Dorn, H. F., Thomas, L. B., Edgcom, J. H., Symeonidis, A. J. Natn. Cancer Inst. 1966, 37, 1. Sheba, Ch., Szeinberg, A., Ramot, B., Adam, A., Ashkenazi, I. Am. J. publ. Hlth, 1962, 52, 1101. Tulchinsky, D., Modan, B. Cancer, N. Y. (in the press). Fishel, B. Unpublished. Steinitz, R. Harefuah, 1966, 71, 347. Martin, C. Paper presented at the American Public Health Association meeting, San Francisco, November, 1966.