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WOUND INFECTION
SUPRARENAL HAEMORRHAGE IN MENINGOCOCCAL SEPTICÆMIA
tube is painful and not devoid of the danger of perforating the dilated and thinned bowel wall, and it is rarely of much use in alleviating distension. ALAN SHORTER. Mount Vernon Hospital, Northwood. SUPRARENAL HÆMORRHAGE IN MENINGOCOCCAL SEPTICÆMIA
SIR,—The Waterhouse-Friderichsen syndrome is not so
rare
as
Dr. Grace, Dr. Harrison and Prof. Davie
suggest in their paper of July 27, for during this year in this hospital we have had at least 7 cases, 4 of which were pulseless on admission but made complete recovery when treated along the lines advocated by our medical superintendent, Dr. G. Emrys Harries (see Lancet, 1940, 1, 522). The method of administration of sulphonamide advocated by Prof. Davie and his colleagues-i.e., oral and intramuscular route-is by no means ideal, for in such fulminating cases the drug should be injected in normal saline intravenously to have its maximum effect. Briefly the treatment Dr. Harries advocates is 1 litre of 5% dextrose in normal saline, intravenously by the Vacoliter drip method, together with 6 c.cm. of the sodium salt of sulphapyridine, with 30-60 c.cm. of meningococcal antitoxin. In addftion, 5 mg. of desoxycorticosterone acetate is given intramuscularly every six hours during the acute state. The rationale of this treatment is :Normal saline to furnish adequate fluids and sodium, which is so vital in cases of adrenal damage ; sulphapyridine to destroy the meningococci ; meningococcal antitoxin to neutralise the toxin and help to destroy organisms ; and desoxycorticosterone acetate to compensate for the adrenal lesions. The potassium content of the blood is high in cases of adrenal damage, so that where bromides are indicated as sedatives the sodium rather than the potassium salt should be given. City Isolation Hospital, Cardiff.
J. M. MURPHY.
SIR,-The article in your issue of July 27 on the so-called Waterhouse-Friderichsen syndrome prompts me to record another such case admitted in May of this year to the Royal Hospital for Sick Children, Edinburgh. The present case emphasises the typical features of this rare but apparently definite entity, the characteristic triad consisting of sudden profound circulatory collapse in a previously healthy infant, and suprarenal apoplexy.
petechial haemorrhages,
A boy aged 10 weeks, who had previously been healthy, began to cry and refused his feed at 6 P.M. on the day before admission. He was given half a teaspoonful of castor oil, and shortly afterwards fell asleep. At 6 A.M. next morning the mother was wakened by the child’s noisy breathing. He was found to be unconscious, and was brought to hospital at 8 A.M. On examination the child was profoundly
unconscious. Temperature subnormal, pulse not palpable, respirations slow, irregular, and gasping. Anterior fontanelle
depressed. Skin
cold. Cyanosis of lips, cheeks, and A few purple petechial haemorrhages the size threepenny piece on the trunk. Numerous petechial haemorrhages pin-head in size on lower limbs. Left pupil smaller than the right. Cerebrospinal fluid clear. Numerous medium-pitched crepitations all over left side of chest. No other abnormalities noted. The child died at 9.40 A.M. Post-mortem examination revealed bilateral diffuse suprarenal haemorrhages. The haemorrhage was confined within the capsules, and had not produced any great enlargement, but appeared to have destroyed practically all the suprarenal tissue. The thymus was considerably above average size, and showed a few small haemorrhages in its substance. Slight tracheitis and bronchitis. Venous congestion of left lung with excess mucus in the bronchi ; some subpleural haemorrhages over the lower lobe. There was no congestion of the brain, or any other evidence of menin-
extremities. of a silver
gitis.
-
I am indebted to Dr. J. McNair Murray for permission to publish this case, and to Dr. Agnes MacGreggor for the post-mortem report. T. G. MACLEOD. J. Edinburgh.
213
WOUND INFECTION H. Ogilvie’s opening sentences in the first of the series of articles on wound infection (Lancet, 1940, 1, 608) contain the whole truth of the matter, and when I read his doubt whether much of the road we have trodden in the last seventy years may not havebeen in the wrong direction I hoped he would give us nothing but truth. But no ; the truth still eludes him and when he set about 37 questions yet to be answered I was sorry for the young surgeon and most fearful for the fate of the wounded soldier. Mr. Ogilvie is right, we have taken a wrong turning. That serious deviation is to be seen in his remark: " Attention was concentrated upon killing the bacteria, and little was known of the defences of the tissues." A more direct departure from Lister’s teaching and a more essentially harmful neglect of the principle of the antiseptic method could not be imagined. Lister spent very little effort in cleansing a wound ; that is for the natural inhibitory and reliable defences to deal with, which Lister was the first to use and not abuse. The next step was to prevent secondary infection of that wound by the intelligent application of an antiseptic dressing and to protect the wound from irritation, even that of antiseptics. If after reading Lister’s " Collected Papers " anyone tells me I am wrong I will ask him to read them again. My opinion is that we have not merely taken a wrong turning but have faced wrongabout, not merely right-about, and have now deeply penetrated the pre-Listerian era, picked up foreign ideas, all unavailing. No trace of the antiseptic method exists today. It alone can answer the 37 questions. A. C. F. HALFORD. Brisbane, Queensland.
SIR,—Mr. W.
THE TIME FOR UNITY
SIR,—Three times in the past year an acute awareness of public needs has been voiced in leading and other articles in THE LANCET. Three times Sir Maurice Cassidy, Sir Charles Gordon-Watson and Dr. Walshe havedenied the need for change in letters of identical
implication. The implication
of this discussion is, however, much wider than your article of July 13 which inspired it. It was a pity that the phrase " in peace-time doctors are largely luxuries " obscured the real evidence of an awakening social conscience which has been as little active in medicine as in all other professions. It is not that change is unnecessary, or that it can be resisted ; change is continuous, and the old problems of social weal have become more acute in the present social phase. The problems of air-raid casualties, the evacuation of children and removal of communities, and the probability of huge localised peak loads will test medical administrative capacity to the full, but still greater problems will follow. Food rationing in an undernourished population, rise in the cost of living and the cutting down of health services will inevitably lead to increased disease incidence. Experts convince me that tuberculosis will increase-the German figures after the last war were appalling. Nine months of this war elapsed before scientific committees were appointed to advise on food problems and the treatment of war wounds. Dare one hope that strong executiveaction will follow their work ? Are not medical men deeply interested in these things ? Must they always follow precedent and " our glorious tradition" and await disaster before they act ? Have%ve no vision ? It is only too easy to ignore our medical consciences, and therefore we require a profession whose reading of social requirements is not biased, consciously or unconsciously, by self-interest and by trivial desires to perpetuate the hypothetical freedom of our declining years in Harley Street. The adoption of Sir Maurice Cassidy’s view that we should all join a particular organisation could only therefore organise and strengthen resistance to change. The Royal Colleges have also failed to create a lead in matters widely medical, and one of these bodies has recently confessed its failure to influence effectively the Ministry of Health on two problems of paramount the prophylaxis of diphtheria and the pasteurisation of milk. It is impossible to isolate the medical problem from its environment, and it is useless to close one’s eyes to
importance,
tube is painful and not devoid of the danger of perforating the dilated and thinned bowel wall, and it is rarely of much use in alleviating distension. ALAN SHORTER. Mount Vernon Hospital, Northwood. SUPRARENAL HÆMORRHAGE IN MENINGOCOCCAL SEPTICÆMIA
SIR,—The Waterhouse-Friderichsen syndrome is not so
rare
as
Dr. Grace, Dr. Harrison and Prof. Davie
suggest in their paper of July 27, for during this year in this hospital we have had at least 7 cases, 4 of which were pulseless on admission but made complete recovery when treated along the lines advocated by our medical superintendent, Dr. G. Emrys Harries (see Lancet, 1940, 1, 522). The method of administration of sulphonamide advocated by Prof. Davie and his colleagues-i.e., oral and intramuscular route-is by no means ideal, for in such fulminating cases the drug should be injected in normal saline intravenously to have its maximum effect. Briefly the treatment Dr. Harries advocates is 1 litre of 5% dextrose in normal saline, intravenously by the Vacoliter drip method, together with 6 c.cm. of the sodium salt of sulphapyridine, with 30-60 c.cm. of meningococcal antitoxin. In addftion, 5 mg. of desoxycorticosterone acetate is given intramuscularly every six hours during the acute state. The rationale of this treatment is :Normal saline to furnish adequate fluids and sodium, which is so vital in cases of adrenal damage ; sulphapyridine to destroy the meningococci ; meningococcal antitoxin to neutralise the toxin and help to destroy organisms ; and desoxycorticosterone acetate to compensate for the adrenal lesions. The potassium content of the blood is high in cases of adrenal damage, so that where bromides are indicated as sedatives the sodium rather than the potassium salt should be given. City Isolation Hospital, Cardiff.
J. M. MURPHY.
SIR,-The article in your issue of July 27 on the so-called Waterhouse-Friderichsen syndrome prompts me to record another such case admitted in May of this year to the Royal Hospital for Sick Children, Edinburgh. The present case emphasises the typical features of this rare but apparently definite entity, the characteristic triad consisting of sudden profound circulatory collapse in a previously healthy infant, and suprarenal apoplexy.
petechial haemorrhages,
A boy aged 10 weeks, who had previously been healthy, began to cry and refused his feed at 6 P.M. on the day before admission. He was given half a teaspoonful of castor oil, and shortly afterwards fell asleep. At 6 A.M. next morning the mother was wakened by the child’s noisy breathing. He was found to be unconscious, and was brought to hospital at 8 A.M. On examination the child was profoundly
unconscious. Temperature subnormal, pulse not palpable, respirations slow, irregular, and gasping. Anterior fontanelle
depressed. Skin
cold. Cyanosis of lips, cheeks, and A few purple petechial haemorrhages the size threepenny piece on the trunk. Numerous petechial haemorrhages pin-head in size on lower limbs. Left pupil smaller than the right. Cerebrospinal fluid clear. Numerous medium-pitched crepitations all over left side of chest. No other abnormalities noted. The child died at 9.40 A.M. Post-mortem examination revealed bilateral diffuse suprarenal haemorrhages. The haemorrhage was confined within the capsules, and had not produced any great enlargement, but appeared to have destroyed practically all the suprarenal tissue. The thymus was considerably above average size, and showed a few small haemorrhages in its substance. Slight tracheitis and bronchitis. Venous congestion of left lung with excess mucus in the bronchi ; some subpleural haemorrhages over the lower lobe. There was no congestion of the brain, or any other evidence of menin-
extremities. of a silver
gitis.
-
I am indebted to Dr. J. McNair Murray for permission to publish this case, and to Dr. Agnes MacGreggor for the post-mortem report. T. G. MACLEOD. J. Edinburgh.
213
WOUND INFECTION H. Ogilvie’s opening sentences in the first of the series of articles on wound infection (Lancet, 1940, 1, 608) contain the whole truth of the matter, and when I read his doubt whether much of the road we have trodden in the last seventy years may not havebeen in the wrong direction I hoped he would give us nothing but truth. But no ; the truth still eludes him and when he set about 37 questions yet to be answered I was sorry for the young surgeon and most fearful for the fate of the wounded soldier. Mr. Ogilvie is right, we have taken a wrong turning. That serious deviation is to be seen in his remark: " Attention was concentrated upon killing the bacteria, and little was known of the defences of the tissues." A more direct departure from Lister’s teaching and a more essentially harmful neglect of the principle of the antiseptic method could not be imagined. Lister spent very little effort in cleansing a wound ; that is for the natural inhibitory and reliable defences to deal with, which Lister was the first to use and not abuse. The next step was to prevent secondary infection of that wound by the intelligent application of an antiseptic dressing and to protect the wound from irritation, even that of antiseptics. If after reading Lister’s " Collected Papers " anyone tells me I am wrong I will ask him to read them again. My opinion is that we have not merely taken a wrong turning but have faced wrongabout, not merely right-about, and have now deeply penetrated the pre-Listerian era, picked up foreign ideas, all unavailing. No trace of the antiseptic method exists today. It alone can answer the 37 questions. A. C. F. HALFORD. Brisbane, Queensland.
SIR,—Mr. W.
THE TIME FOR UNITY
SIR,—Three times in the past year an acute awareness of public needs has been voiced in leading and other articles in THE LANCET. Three times Sir Maurice Cassidy, Sir Charles Gordon-Watson and Dr. Walshe havedenied the need for change in letters of identical
implication. The implication
of this discussion is, however, much wider than your article of July 13 which inspired it. It was a pity that the phrase " in peace-time doctors are largely luxuries " obscured the real evidence of an awakening social conscience which has been as little active in medicine as in all other professions. It is not that change is unnecessary, or that it can be resisted ; change is continuous, and the old problems of social weal have become more acute in the present social phase. The problems of air-raid casualties, the evacuation of children and removal of communities, and the probability of huge localised peak loads will test medical administrative capacity to the full, but still greater problems will follow. Food rationing in an undernourished population, rise in the cost of living and the cutting down of health services will inevitably lead to increased disease incidence. Experts convince me that tuberculosis will increase-the German figures after the last war were appalling. Nine months of this war elapsed before scientific committees were appointed to advise on food problems and the treatment of war wounds. Dare one hope that strong executiveaction will follow their work ? Are not medical men deeply interested in these things ? Must they always follow precedent and " our glorious tradition" and await disaster before they act ? Have%ve no vision ? It is only too easy to ignore our medical consciences, and therefore we require a profession whose reading of social requirements is not biased, consciously or unconsciously, by self-interest and by trivial desires to perpetuate the hypothetical freedom of our declining years in Harley Street. The adoption of Sir Maurice Cassidy’s view that we should all join a particular organisation could only therefore organise and strengthen resistance to change. The Royal Colleges have also failed to create a lead in matters widely medical, and one of these bodies has recently confessed its failure to influence effectively the Ministry of Health on two problems of paramount the prophylaxis of diphtheria and the pasteurisation of milk. It is impossible to isolate the medical problem from its environment, and it is useless to close one’s eyes to
importance,