CHILDREN IN POINTED SHOES
1
598 1. Husain, T. J. Path. Bact. 1953, 66, 347. be more careful in finding his way through the Alice-in- Wonderland regulations of the N.H.S. The latest of these oddities to come to my notice is the requiring of a family practitioner to certify a domiciliary consultation to the regional board: " That a Consultant has seen a ’ bona fides ’ residential patient in a nursing home." In other words, the regional board are requiring me, who is not employed by them, to give a certificate to their accountants " that Dr. Physic, F.R.C.P., is an honest man who is not bilking them". How did the Royal Colleges allow this monstrous insult to their members to be perpetrated! Why do the accoun- tants of the regional board need the written word of a " bottom- rung " G.P. in addition to that of their own bona-fide top-rung, employees-the consultants? The wood of N.H.S. administra- tion is indeed delightfully Tulgey! R. HOWARD. Burley, near Ringwood, Hampshire. CHILDREN IN POINTED SHOES P. D. H. CHAPMAN. SIR,-So long as mothers wear deforming shoes, their daughters will crave to wear them also. Why women want to wear them is a matter for conjecture. Probably the explanation is their desire to appear as rich and leisured women, a motivation similar to that of Chinese ladies in past times who cultivated enormous fingernails. Bridlington. PREVENTION AND TREATMENT OF BEDSORES BY SILICONE CREAM M. S. PATHY. Amersham General Hospital, Buckinghamshire. SiR,-I should like to comment on the statement by Dr. Kendall (Feb. 27) that a silicone cream containing dienoestrol " is excellent for the prevention of sores when the skin becomes red at the pressure points (and) for superficial bedsores...." The value of local treatment in the prevention of pressure sores has been overemphasised, because of the generally held belief that the essential pathology of a pressure sore is an ischaemic necrosis which initially involves the skin, and may then progress to successively involve the subcutaneous tissues and muscle. Husain has shown that in an area subjected to pressure there is considerable necrosis of muscle even at a stage where the only clinical finding is erythema of the skin. I have had histological sections made from similar pressure " sores " and these have shown marked muscle necrosis and have confirmed Husain’s findings. The basic cause of a pressure sore is, of course, a reduction in the blood-supply to the tissues of the compressed area. Various factors influence the length of time that ischxmia must be maintained to cause necrosis, but it is probably as little as four hours. Skin, fat, and muscle possess different degrees of resistance to ischasmia, muscle being less resistant than skin or fat. It is often with surprise that, on removing a superficial layer of necrotic tissue, one finds an enormous cavity going down to bone. In some pressure sores a small blister develops and when the skin is removed the under- lying tissues may appear healthy. Only too often it is assumed that what is required is some local application to enable the lesion to re-epithelialise and then all will be well. What in fact is required is relief of pressure. Local applications are a useful adjunct and no more. The same may be said for a pressure area which shows no more than local erythema of the skin. I have no wish to minimise the importance of care of the skin. My object is to appeal for reorientation of ideas on pressure sores. Ideas are never without influence on practice. If the initial injury is held to be localised to the skin, attention and treatment will be focused here; but if it is conceded that necrosis develops in the muscle at an early stage, the application of ointments or spirit to the 1. Clowdus, B. F., Higgins, J. A., Rosevear, J. W., Summerskill, W. H. J. Proc. Mayo Clin. 1960, 55, 97. skin will be seen to be of secondary importance. Turning a patient off his pressure areas in order to apply ointment or spirit to the skin is probably of more importance than the intrinsic value of the local application. TREATMENT OF INFECTIONS IN HOSPITAL I. M. LIBRACH. Chadwell Heath Hospital, Romford, Essex. SiR,-I cannot let Dr. Everley Jones’ letter of Feb. 13 go unanswered. He asks is the increase in streptococcal infections widespread ? As a paediatrician, no doubt this comes as a surprise, but to workers in infectious diseases hospitals this is no new thing. Notification of scarlet fever has been used as an index to the incidence of srreptococcal infections for many years. The annual report of the Ministry of Health for 1958, published in November, 1959, states that the total number of corrected notifications of this disease has been higher than it has been since 1954. The exact annual figures are: 1954, 43,026; 1955, 32,619; 1956, 33,103; 1957, 29,547; 1958, 38,853. With regard to antibiotics and immunity, I would say that the use-especially if indiscriminate-of penicillin or any other antibiotic, mitigates against the establishment of firm immunity by killing off responsible organisms, either totally or partially before adequate antibody stimulation can be developed. In other words, widespread use of antibiotics might well provide an increase of infection rather than the reverse, including in the case of the streptococcus the survival of type-12 strain whose nephrogenic properties have been well established. Surely the only reliable method of reducing its incidence would be an actively immunising prophylactic similar to the toxoids of diphtheria and tetanus rather than killed vaccines. As far as I am aware the biological difficulties associated with the isolation of such an agent seem at present-unfortunately- to be insuperable. I would say that few, if any, authorities still recommend the use of prophylactic scarlatinal toxin because it is troublesome to use and its indications are limited to this condition. DIURETIC EFFECT OF SPIROLACTONE SC-9420 SIR,--’The important observations of Dr. Cejka and his colleagues (Feb. 6) on the diuretic effect of sc-9420 (’ Aldactone ’) over a 9-day period in a patient with heart- disease necessarily failed to emphasise the clinical signifi- cance of this compound, because of the brevity of their trial. Our experiences 1 in 8 patients with cirrhosis and refractory ascites, involving 155 days of hospital treat- ment with the drug after appropriate control periods, showed a remarkable response in every case. Prior to therapy, sodium excretion was less than 4 mEq. in 24 hours, and neither weight-loss nor a negative sodium balance could be induced by a low-sodium diet or the use of mercurial diuretics, chlorothiazide, and/or prednisone. Aldactone alone had a weak but definite action on body-weight and sodium excretion, but the greatest effect followed the use of the standard diuretics (which had previously been ineffective) in conjunction with aldactone. On this regime, weight-losses in individual patients of up to 51/2 lb. daily occurred, and these were associated with 24-hour sodium urinary excretions of up to 337 mEq. Subsequent studies (> 200 patient-days) have confirmed the efficacy of the drug, and no toxic effect has been observed. Besides indicating that " resistance " to standard treatment in such patients is to a great extent the result of hyperaldo- steronism, which could in part be a response to therapy with sodium restriction and diuretics, rather than a progressive
Transcript of CHILDREN IN POINTED SHOES
598
1. Husain, T. J. Path. Bact. 1953, 66, 347.
be more careful in finding his way through the Alice-in-Wonderland regulations of the N.H.S.The latest of these oddities to come to my notice is the
requiring of a family practitioner to certify a domiciliaryconsultation to the regional board: " That a Consultant hasseen a ’ bona fides ’ residential patient in a nursing home."
In other words, the regional board are requiring me, who isnot employed by them, to give a certificate to their accountants" that Dr. Physic, F.R.C.P., is an honest man who is not bilkingthem". How did the Royal Colleges allow this monstrousinsult to their members to be perpetrated! Why do the accoun-tants of the regional board need the written word of a
" bottom-
rung " G.P. in addition to that of their own bona-fide top-rung,employees-the consultants? The wood of N.H.S. administra-tion is indeed delightfully Tulgey!
R. HOWARD.Burley, near Ringwood,Hampshire.
CHILDREN IN POINTED SHOES
P. D. H. CHAPMAN.
SIR,-So long as mothers wear deforming shoes, theirdaughters will crave to wear them also. Why womenwant to wear them is a matter for conjecture. Probablythe explanation is their desire to appear as rich andleisured women, a motivation similar to that of Chineseladies in past times who cultivated enormous fingernails.
Bridlington.
PREVENTION AND TREATMENT OF
BEDSORES BY SILICONE CREAM
M. S. PATHY.Amersham General Hospital,
Buckinghamshire.
SiR,-I should like to comment on the statement byDr. Kendall (Feb. 27) that a silicone cream containingdienoestrol " is excellent for the prevention of soreswhen the skin becomes red at the pressure points (and)for superficial bedsores...."The value of local treatment in the prevention of pressure
sores has been overemphasised, because of the generally heldbelief that the essential pathology of a pressure sore is anischaemic necrosis which initially involves the skin, and maythen progress to successively involve the subcutaneous tissuesand muscle. Husain has shown that in an area subjected topressure there is considerable necrosis of muscle even at a
stage where the only clinical finding is erythema of the skin.I have had histological sections made from similar pressure" sores " and these have shown marked muscle necrosis andhave confirmed Husain’s findings.The basic cause of a pressure sore is, of course, a reduction
in the blood-supply to the tissues of the compressed area.Various factors influence the length of time that ischxmiamust be maintained to cause necrosis, but it is probably aslittle as four hours. Skin, fat, and muscle possess differentdegrees of resistance to ischasmia, muscle being less resistantthan skin or fat. It is often with surprise that, on removinga superficial layer of necrotic tissue, one finds an enormouscavity going down to bone. In some pressure sores a smallblister develops and when the skin is removed the under-
lying tissues may appear healthy. Only too often it is assumedthat what is required is some local application to enable thelesion to re-epithelialise and then all will be well. What infact is required is relief of pressure. Local applications area useful adjunct and no more. The same may be said for apressure area which shows no more than local erythema of theskin.
I have no wish to minimise the importance of care ofthe skin. My object is to appeal for reorientation of ideason pressure sores. Ideas are never without influence on
practice. If the initial injury is held to be localised to theskin, attention and treatment will be focused here; but ifit is conceded that necrosis develops in the muscle at anearly stage, the application of ointments or spirit to the 1. Clowdus, B. F., Higgins, J. A., Rosevear, J. W., Summerskill, W. H. J.
Proc. Mayo Clin. 1960, 55, 97.
skin will be seen to be of secondary importance. Turninga patient off his pressure areas in order to apply ointmentor spirit to the skin is probably of more importance thanthe intrinsic value of the local application.
TREATMENT OF INFECTIONS IN HOSPITAL
I. M. LIBRACH.Chadwell Heath Hospital,
Romford, Essex.
SiR,-I cannot let Dr. Everley Jones’ letter of Feb. 13go unanswered. He asks is the increase in streptococcalinfections widespread ? As a paediatrician, no doubtthis comes as a surprise, but to workers in infectiousdiseases hospitals this is no new thing.
Notification of scarlet fever has been used as an index to theincidence of srreptococcal infections for many years. Theannual report of the Ministry of Health for 1958, publishedin November, 1959, states that the total number of correctednotifications of this disease has been higher than it has beensince 1954. The exact annual figures are: 1954, 43,026; 1955,32,619; 1956, 33,103; 1957, 29,547; 1958, 38,853.With regard to antibiotics and immunity, I would say that
the use-especially if indiscriminate-of penicillin or any otherantibiotic, mitigates against the establishment of firm
immunity by killing off responsible organisms, either totallyor partially before adequate antibody stimulation can be
developed.In other words, widespread use of antibiotics might well
provide an increase of infection rather than the reverse,including in the case of the streptococcus the survival of
type-12 strain whose nephrogenic properties have been wellestablished.
Surely the only reliable method of reducing its incidencewould be an actively immunising prophylactic similar to thetoxoids of diphtheria and tetanus rather than killed vaccines.As far as I am aware the biological difficulties associated withthe isolation of such an agent seem at present-unfortunately-to be insuperable. I would say that few, if any, authoritiesstill recommend the use of prophylactic scarlatinal toxinbecause it is troublesome to use and its indications are limitedto this condition.
DIURETIC EFFECT OF SPIROLACTONE SC-9420
SIR,--’The important observations of Dr. Cejka andhis colleagues (Feb. 6) on the diuretic effect of sc-9420(’ Aldactone ’) over a 9-day period in a patient with heart-disease necessarily failed to emphasise the clinical signifi-cance of this compound, because of the brevity of theirtrial. Our experiences 1 in 8 patients with cirrhosis andrefractory ascites, involving 155 days of hospital treat-ment with the drug after appropriate control periods,showed a remarkable response in every case.
Prior to therapy, sodium excretion was less than 4 mEq. in24 hours, and neither weight-loss nor a negative sodium balancecould be induced by a low-sodium diet or the use of mercurialdiuretics, chlorothiazide, and/or prednisone. Aldactone alonehad a weak but definite action on body-weight and sodiumexcretion, but the greatest effect followed the use of thestandard diuretics (which had previously been ineffective) inconjunction with aldactone. On this regime, weight-losses inindividual patients of up to 51/2 lb. daily occurred, and thesewere associated with 24-hour sodium urinary excretions of upto 337 mEq. Subsequent studies (> 200 patient-days) haveconfirmed the efficacy of the drug, and no toxic effect has beenobserved.
Besides indicating that " resistance " to standard treatmentin such patients is to a great extent the result of hyperaldo-steronism, which could in part be a response to therapy withsodium restriction and diuretics, rather than a progressive
