1295 of an artificial airway;1-5 indeed Blanc et al. suggest that any other approach "could give rise to severe legal complications and must be totally abandoned." The proportion of patients satisfactorily managed with conservative measures is generally small: in four units where medical treatment was tried first, the numbers whó ultimately escaped intubation were 0 of 20,8 2 of 27,9 26 of 116,6and 29 of 55.5 In this last series of 55, 3 of the "observed" patients subsequently had total respiratory arrest, and 1 could not be resuscitated.5 Even 1 such death argues strongly for intubation as soon as the diagnosis is made. Whether tracheostomy should follow intubation is more debatable. A tracheostomy tube may be less apt to block, and does not pass through highly inflamed tissues. Complications, however, may arise in over a third of cases and include pneumothorax, tracheal stenosis, unsightly scarring, and addiction in young children (and the stay in hospital is also longer).3,9 Many children have now been successfully managed with an indwelling nasotracheal tube, and this seems a safe alternative to tracheostomy. The duration of intubation required is usually short, and is becoming shorter as anxsthetists become more confident: in 1967-72 Tos8 intubated his patients for a mean of 39 h; in 1974-77 Breivik and Klaasted9 intubated for 33 h but the mean for 1976-77 was 27 h, and they suggest that even 8-12 h may be sufficient for most children. With such short spells of intubation the risk of damage to mucosa and vocal cords is slight. The value of steroids in epiglottitis is uncertain. As with many acute diseases treated with these drugs, there is no hard evidence that they confer any benefit, though their use is logical and widespread. Strome and Jaffe10 described 12 patients, 8 of whom recovered with medical treatment including steroids in high doses (dexamethasone lmg/kg 4 hourly). They formed a firm impression that this drug produced real improvement within 1-2 h in their patients, including one from whom it was initially withheld, and they suggest that the duration of intubation, when required, may be shortened. A carefully controlled trial is needed to establish this last point, though it will be hard for any one unit to find enough patients to provide a firm answer in a short time. Meanwhile a good case can be made for the use, in a lifethreatening condition, of a drug which may be beneficial and rarely produces side-effects in short courses. If steroids are of any value, large doses are probably needed. Vigorous treatment of septicaemia is hardly less important than maintenance of airway. Half-hearted use of antibiotics may fail to control the infection, the hxmophilus may seed elsewhere, and even meningitis may ensue.’1 Ampicillin should be given parenterally in high doses (200-400 mg/kg/day); in areas where resistant strains are prevalent, chloramphenicol is best-at least until the sensitivity of the organism is known. Most children dying of epiglottitis in recent years have done so before reaching hospital: this underlines the importance of recognition of the disease and its urgent implications. With current knowledge of the disease and its

8. 9. 10. 11.

Tos, M. Archs Otolar. 1973, 97, 373. Breivik, H., Klaasted, O. Br. J. Anœsth. 1978, 50, 505. Strome, M., Jaffe, B. Laryngoscope, 1974, 84, 921. Wolman, B., Reddy, P. M. M., Murtaza, L. N. Br. med. J 1972, i, 246

management,

fering

from

as

Morus

epiglottitis

Jones

admitted

says, "No

patient suf-

hospital

alive should

to

die. 112 A NEW ROLE FOR BOTULINUM? measures can lessen the more and more serious consequences of specific widespread water-borne or food-borne microbial pathogens, much of the world has yet to see these benefits. Even in "developed" countries they are not uniformly achieved, nor can specific agents of bowel malfunction always be identified. Round many an intestinal corner there may yet lurk microbial felons to be discovered. Not so long ago rotaviruses seemed to fill such a role, only to be displaced, in some respects, by campylobacters. Now it seems to be the turn of Clostridium botulinum-by no means a newcomer on the microbial scene but emerging in a previously unrecognised pathogenic context. As a neuroparalytic intoxication resulting from the ingestion of food contaminated with C. botulinum toxin, formed therein by microbial growth, botulism has been recognised mainly amongst adults and children; infants are virtually excluded, doubtless because of their different dietary habits. Seven distinct types of C. botulinum, designated A to G, have been identified on the basis of the serological specificity of toxins produced. In Britain, types A and B have affected human beings, but the number of cases reported this century has been only 21. 12 deaths resulted during the seven incidents, and no fewer than 8 deaths happened in a single episode-the tragedy in 1922 when a party of fishers at Loch Maree in north-west Scotland ate sandwiches containing contaminated duck paste. Not that the organisms are absent from the British environment; but botulism certainly does not show itself in Britain as it does in France, Iran, the U.S.S.R., Japan, and the U.S.A. The low incidence in the United Kingdom may well be due to the unpopularity of home preservation for meats, poultry, game, fish, or vegetables (other than by freezing); to a general antipathy to raw fish; and to commercial application of a processing routine aimed at preventing contamination with C. botulinum. In the U.S.A. C. botulinum food-poisoning is a long-running saga,2 and botulism has also resulted from microbial growth in wounds.3 Lately there. have been reports,4particularly from California, of a new syndrome of botulism affecting infants. Evidently the ingested organism or its spores can grow in the infant gut and produce toxin which then diffuses into the body, to produce sudden respiratory arrest. Thus the condition may present as sudden-infant-death syndrome. Leaders in this sphere have been workers from the California State Department of Health,5 and at the front of this issue Dr Arnon and his co-workers record their findings in material from a large series of infants, alive and dead. This report does suggest that the toxin is responsible for some cases of S.LD.S. And on p. 1277 is the first report of infant botulism from outside the U.S.A. Doubtless more will come to light once clinicians are

THOUGH

public-health

1. Gilbert, R. J. Postgrad. med. J. 1974, 50, 603. 2 Foodborne and Waterborne Disease Outbreaks. Annual reports, 1966 Center for Disease Control, Atlanta, Georgia.

3. Merson, M. H., Dowell, V. R. New Engl J. Med. 1973, 289, 1005. 4. Morbid. Mortal. wkly Rep 1978, 27, no. 3, p. 17. 5. Midura, T F., Arnon, S. S Lancet, 1976, ii, 934.

et

seq.,

1296 alert

to the presentation-acute hypotonicity and weakin an infant who has earlier been constipated. The link between this and the presence of C. botulinum or its toxin seems clear. We now need information not only on the clinical relationships involved6 but also on the best toxicological methods for epidemiological investiness

gations. "THEM" AND THE N.H.S. WHEN anonymous public servants stop serving and ruling, the result is a bureaucracy, a method of government rightly deplored. But what would we do without the faceless bureaucrat: who else to blame if officials, the administration, or, even better, "they" are not around when things go wrong? Over the past few years administration in the public sector in the U.K. has had a bad Press, and nowhere more than in the National Health Service. A research paper,’ based on over five hundred interviews with staff, was last week added to the mounting pile of evidence to the Royal Commission on the National Health Service that the N.H.S. is somehow overadministered. Though commissioned by them start

(other reports, on finance and on patients’ attitudes to hospital service, are to follow) the research on staff opinions appears without comment from Sir Alec Merrison and his colleagues. There are those who believe that any money not spent directly on patients is money wasted. Even allowing for hyperbole, this is unreasonable : the bill, expressed as a percentage of the whole, is not excessive when set beside what private or public industry or bodies such as the Medical Research Council or charitable foundations spend on running their affairs. the

Those who say that the administrative side is overmanned are on slightly firmer ground: in the 1970s administrators, clerks, and the like have increased in number, as the Humberside exercise showed,2 and Professor Holland, in a reasoned defence of the administrator,3 accepted that there had been some unnecessary growth. Standing firmly upon rock are those who complain, not that we have too many administrators or that we spend too much on their accommodation-tactless though some of this indulgence has seemed in these days of strict financial control elsewhere-but that administration, as reflected in what it takes to make a decision, has become insufferably complex. And all this is before planning--one of the major objectives of the new N.H.S.-has got off the ground. In the N.H.S. today "flow diagram" is a complete misnomer for the obstacle course set in the way of anyone rash enough to want a new registrar post, to wish to send a junior colleague on a training course, to set up a new shift system, or to get a coat-hook screwed to a door. The architects of the reorganised N.H.S. will say that they never meant this to happen, and it is true that early thoughts on how to improve management did not envisage such a complex committee structure or such elaborate consultation arrangements."... in March 1976, no fewer than 41 different official groups 6. 7.

Urquhart, G. E. D., Grist, N. R. ibid. p. 1411.

Turnbull, P. C. B., Ghosh, A. C., Gilbert, R. J., Melling, J. ibid. 1. Royal Commission on the National Health Service., Research Paper

no.

1.

H.M.

Stationery Office. £3·75. 2. Brown, R. G. S., Griffin, S., Haywood, S. C. New tute of Health Studies, University of Hull, 1975. 3. Holland, W W.

Lancet, 1976, i, 33.

were involved to some extent in manpower planning within the NHS... In addition, consultation procedures are cumbersome. In one quite small AHA, for instance, any document sent out for consultation (and these days most are) requires over 250 copies; and every comment must be circulated to the other 249 recipients of the original."4 All committees need servicing and every document copied requires work by someone in administration. The years before, during, and after reorganisation have been rich in the reassertion of old professional empires and in the creation of new ones. The politicians gave in, right and left, and the early vision became clouded by compromise. "Opposition from the medical profession-and, subsequently, from other health professions-was bought off, at the cost of entangling the new structure in a web of consultative committees."5 The Royal Commission research paper has examples of this. Most of those interviewed felt that integrationanother promise of the new structure--could not be fully achieved while the family practitioner committees remained aloof. The professions involved sought this independence, and when they got their "hot line" to the Department of Health they took precious little interest in reorganisation from then on. Had reorganisation taken place before trade-union power, or the notion of direct consumer representation, came on the N.H.S. scene the result might have been different. There seems, too, to be a general disillusionment with the concept of co-terminosity with local-authority boundaries and with the four-tier English structure of Department, region, area, and district: political considerations were involved in these decisions too. The research team’ backs up its interviews with four field studies--of planning, responsibilities for servicing biomedical equipment (empire building enough here), committees of inquiry by members of an area health authority, and two hospital closures (Poplar Hospital and the Invalid and Crippled Children’s Hospital). At Poplar closure was opposed within the community; there was less opposition at the other hospital, but both illustrate the "tensions between participation and planning", a point more starkly brought out by the saga of the Elizabeth Garrett Anderson Hospital. No pretext has been too flimsy for the Secretary of State, almost from one day to another, to announce some subtle change of attitude to the closure of this hospital, which is a redundant architectural anachronism providing, in an age of sex equality, a socially reactionary service denied the vast majority of women elsewhere in the country. The danger is that tension between planners and workers and the community will become a rift. Managers, with some justice, see themselves as having responsibility increasingly without power, while the consultative machine seems to have more and more power, at least to delay, with responsibility to faction rather than to the greater good. The best that can be said of N.H.S. reorganisation is that the service to patients has not deteriorated. Staff from the department of government at Brunel University’ get that impression from their interviews covering hundreds of hours: at the same university works one of the architects of the new N.H.S. who, in 1973, said that Inc. Submission National Health Service. January, 1977. 5. Klein, R. New Society, Sept. 22, 1977. 6. Jaques, E. See Lancet, 1973, i, 499.

4. McKinsey & Company,

Bottles: Old Wine? Insti-

to

the

Royal

Commission

on

the

A new role for botulinum?

1295 of an artificial airway;1-5 indeed Blanc et al. suggest that any other approach "could give rise to severe legal complications and must be totall...
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