471 ORAL THERAPY OF INFANT DIARRHŒA
. SIR,-Immediate oral therapy at home by the mother herself, using the sugar-salt solution, offers a real prospect of reducing mortality from gastroenteritis among pre-school children in the developing world. The sugar-salt solution enables the mother to take action within her capability and resources to tackle a disease which she will have seen only too frequently and fear as the commonest cause of death among young children. In Lagos, Nigeria, knowledge of the treatment has diffused rapidly in a low-income community which is served by a clinic run by the Institute of Child Health. In a recent study, even women expecting their first child and others who had never used the service were able to describe the sugar-salt solution treatment taught to all who attend the clinic. However, of the 217 women who described the method, considerably less than half (34%) could give the correct proportions of sugar and salt to use (taught as four teaspoons and one-quarter teaspoon respectively in a standard local beer bottle filled with water). Most errors involved the use of too much salt. In nearly half these cases, four times too much salt was described, and in 3 cases sixteen times too much salt. Under these circumstances we can expect a possible increase in children admitted with hypernatraemia, and the whole method will fall into disrepute. Any attempt to transfer health skills to mothers in developing countries must recognise, as in this example, the problems posed by lack of education and unfamiliarity with measurement terms such as "one-quarter" or even "a teaspoon". What is required is a simple measuring spoon giving the actual quantity to be used. Manufactured on a large scale in plastic, this would be inexpensive. Ideally, every mother of a pre-school child should have one, but where this is not possible all health workers should have such spoons so that they can measure into a mother’s hand the correct amounts. In this way the mother can make correct use of a treatment which has such potential for saving lives. OLIKOYE RANSOME-KUTI Institute of Child Health, Lagos, Nigeria
ANNE BAMISAIYE
POST-TRAUMATIC SKULL RADIOGRAPHY ’
SiR,—The article by Dr Eyes and Dr Evans (July 8, p. 85) is the latest in a seriesl-5 which pointed out the low yield of fractures, pineal shifts, and therapeutic decisions from posttraumatic skull X-rays. The prevalence of fractures in these series decreased from 15% to 1-9%, which suggests that clinicians are X-raying head-trauma patients in a more and more. unselective manner, even though they are aware of the low yield.6 But the decision to X-ray after head trauma is more than just "routine investigation" as Eyes and Evans suggest, 2 or a futile search for a rare and useless finding. and Evans that send imply physicians everybody with Eyes head trauma for skull radiography but this is not supported by their data. The denominator in their work should not have been the cohort of people X-rayed, but the entire cohort of people with head trauma. In the Seattle, Washington area, physicians X-ray 40-70% of the patients presenting with head trauma (unpublished): this is too many, but they are not totally indiscriminate. Eyes and Evans also imply that active treatment is the only worthwhile result of skull radiography. But even negative skull X-rays can have value for the clinician when combined with physical examination. Active treatments can be avoided, and
or intoxicated patient other diagbe considered. In Eyes and Evans’ series, might it have been the negative skull films which allowed the stay of so many patients to be only one night? The savings from less hospital days could easily outweigh the cost of more skull films. Eyes and Evans state that skull radiographs are seldom "the consequence of a clinical decision related to the individual patient." Physicians manning casualty centres are hardly as unthinking as they suggest. Most will go to great lengths to avoid labelling a person well when he is ilF, and the skull X-ray helps them by decreasing uncertainty about tentative diagnoses. The cost of case finding, which was used to calculate the "enormous total cost" of skull radiography,2is useful only when alternative diagnostic techniques for finding a case are being considered.7 It is incorrectly applied to detecting skull fractures where the concern is simply to X-ray or not to X-ray. Instead, marginal costs (price of film and expendable supplies) vs fixed costs (providing equipment, technicians, radiologists, etc.) should be considered. The more X-rays obtained, the smaller the marginal costs become. We agree with Eyes and Evans that post-traumatic skull radiography can and should be reduced. Physicians at this centre review a high-yield indication list each time a post-traumatic skull X-ray is ordered. We have documented a decrease of almost 40% in the rate of X-raying head-trauma patients, with no evidence of adverse outcome in those not radio-
in
a
confused, unconscious,
noses can
graphed. Robert Wood Johnson Clinical Scholars Program,
University of Washington, Seattle 98195, U.S.A.
RICHARD O. CUMMINS JAMES P. LOGERFO
EFFECT OF PHYSIOTHERAPY ON PULMONARY FUNCTION
SIR,-It would be regrettable if, following the paper by Dr Newton .and Mr Stephenson (July 29, p. 228), physiotherapy was considered of little value in the treatment of patients with chest disease. In my view, this treatment, when properly given, is crucial to most therapeutic regimens for the prevention and treatment of respiratory illness. However, it must be appreciated what the treatment is likely to achieve. It is given to overcome sputum retention which not only impedes gas exchange in the lungs but may also lead to areas of atelectasis and pulmonary infection. It is not surprising that these authors could show no obvious benefit from the treatment because it was given for a short time (15 min) and most patients produced 2 ml of sputum or less. Others8 attempting to show the effect of physiotherapy on pulmonary function wisely studied only patients producing a large volume of sputum (30 ml regularly) and found a reduction in airways obstruction after 20-30 min of physiotherapy (breathing exercises, chest vibration, and percussion in different postures). In severe asthma hypercapnia was associated with large volumes of bronchial secretion and when this was coughed up after 9 vigorous therapy the Paco2 returned to a safe level. I asked Miss M. Auld (superintendent physiotherapist, Grampian Health Board) how she and her colleagues would manage the type of patient described by Newton and Stephenson. They would be given 20-30 min of physiotherapy initially followed by supervised physiotherapy three times a day. She estimates that 30 ml of sputum would be produced initially and on average at least 60 ml in 24 h. University Department of Medicine,
1. St John, E.G. Am. J. Roent. 1956, 76, 315. 2. Bell, R. S., Loop, J. W. New Engl. J. Med. 1971, 284, 236. 3. Harwood-Nash, D. C., Hendrick, E. B., Hudson, A. R.
101, 151. 4. Roberts, F., Shopfner, C. H. Am. J. Roent. 1972, 114, 230. 5. Jergens, M. E., and others. West. J. Med. 1977, 127, 1. 6. Jennett, B. Br. med. J. 1978, i, 1601.
Foresterhill, Aberdeen AB9 2ZD
K. N. V. PALMER
Radiology, 1971, 7. Bunker, J. P. (editor) Costs, Risks, and Benefits of Surgery. New York, 1977. 8 Cochrane, G. M., Webber, B. A., Clarke, S. W. Br. med. J. 1977, ii, 1181. 9. Rebuck, A. S., Read, J. Am. J. Med. 1971, 51, 788.
. SIR,-Immediate oral therapy at home by the mother herself, using the sugar-salt solution, offers a real prospect of reducing mortality from gastroenteritis among pre-school children in the developing world. The sugar-salt solution enables the mother to take action within her capability and resources to tackle a disease which she will have seen only too frequently and fear as the commonest cause of death among young children. In Lagos, Nigeria, knowledge of the treatment has diffused rapidly in a low-income community which is served by a clinic run by the Institute of Child Health. In a recent study, even women expecting their first child and others who had never used the service were able to describe the sugar-salt solution treatment taught to all who attend the clinic. However, of the 217 women who described the method, considerably less than half (34%) could give the correct proportions of sugar and salt to use (taught as four teaspoons and one-quarter teaspoon respectively in a standard local beer bottle filled with water). Most errors involved the use of too much salt. In nearly half these cases, four times too much salt was described, and in 3 cases sixteen times too much salt. Under these circumstances we can expect a possible increase in children admitted with hypernatraemia, and the whole method will fall into disrepute. Any attempt to transfer health skills to mothers in developing countries must recognise, as in this example, the problems posed by lack of education and unfamiliarity with measurement terms such as "one-quarter" or even "a teaspoon". What is required is a simple measuring spoon giving the actual quantity to be used. Manufactured on a large scale in plastic, this would be inexpensive. Ideally, every mother of a pre-school child should have one, but where this is not possible all health workers should have such spoons so that they can measure into a mother’s hand the correct amounts. In this way the mother can make correct use of a treatment which has such potential for saving lives. OLIKOYE RANSOME-KUTI Institute of Child Health, Lagos, Nigeria
ANNE BAMISAIYE
POST-TRAUMATIC SKULL RADIOGRAPHY ’
SiR,—The article by Dr Eyes and Dr Evans (July 8, p. 85) is the latest in a seriesl-5 which pointed out the low yield of fractures, pineal shifts, and therapeutic decisions from posttraumatic skull X-rays. The prevalence of fractures in these series decreased from 15% to 1-9%, which suggests that clinicians are X-raying head-trauma patients in a more and more. unselective manner, even though they are aware of the low yield.6 But the decision to X-ray after head trauma is more than just "routine investigation" as Eyes and Evans suggest, 2 or a futile search for a rare and useless finding. and Evans that send imply physicians everybody with Eyes head trauma for skull radiography but this is not supported by their data. The denominator in their work should not have been the cohort of people X-rayed, but the entire cohort of people with head trauma. In the Seattle, Washington area, physicians X-ray 40-70% of the patients presenting with head trauma (unpublished): this is too many, but they are not totally indiscriminate. Eyes and Evans also imply that active treatment is the only worthwhile result of skull radiography. But even negative skull X-rays can have value for the clinician when combined with physical examination. Active treatments can be avoided, and
or intoxicated patient other diagbe considered. In Eyes and Evans’ series, might it have been the negative skull films which allowed the stay of so many patients to be only one night? The savings from less hospital days could easily outweigh the cost of more skull films. Eyes and Evans state that skull radiographs are seldom "the consequence of a clinical decision related to the individual patient." Physicians manning casualty centres are hardly as unthinking as they suggest. Most will go to great lengths to avoid labelling a person well when he is ilF, and the skull X-ray helps them by decreasing uncertainty about tentative diagnoses. The cost of case finding, which was used to calculate the "enormous total cost" of skull radiography,2is useful only when alternative diagnostic techniques for finding a case are being considered.7 It is incorrectly applied to detecting skull fractures where the concern is simply to X-ray or not to X-ray. Instead, marginal costs (price of film and expendable supplies) vs fixed costs (providing equipment, technicians, radiologists, etc.) should be considered. The more X-rays obtained, the smaller the marginal costs become. We agree with Eyes and Evans that post-traumatic skull radiography can and should be reduced. Physicians at this centre review a high-yield indication list each time a post-traumatic skull X-ray is ordered. We have documented a decrease of almost 40% in the rate of X-raying head-trauma patients, with no evidence of adverse outcome in those not radio-
in
a
confused, unconscious,
noses can
graphed. Robert Wood Johnson Clinical Scholars Program,
University of Washington, Seattle 98195, U.S.A.
RICHARD O. CUMMINS JAMES P. LOGERFO
EFFECT OF PHYSIOTHERAPY ON PULMONARY FUNCTION
SIR,-It would be regrettable if, following the paper by Dr Newton .and Mr Stephenson (July 29, p. 228), physiotherapy was considered of little value in the treatment of patients with chest disease. In my view, this treatment, when properly given, is crucial to most therapeutic regimens for the prevention and treatment of respiratory illness. However, it must be appreciated what the treatment is likely to achieve. It is given to overcome sputum retention which not only impedes gas exchange in the lungs but may also lead to areas of atelectasis and pulmonary infection. It is not surprising that these authors could show no obvious benefit from the treatment because it was given for a short time (15 min) and most patients produced 2 ml of sputum or less. Others8 attempting to show the effect of physiotherapy on pulmonary function wisely studied only patients producing a large volume of sputum (30 ml regularly) and found a reduction in airways obstruction after 20-30 min of physiotherapy (breathing exercises, chest vibration, and percussion in different postures). In severe asthma hypercapnia was associated with large volumes of bronchial secretion and when this was coughed up after 9 vigorous therapy the Paco2 returned to a safe level. I asked Miss M. Auld (superintendent physiotherapist, Grampian Health Board) how she and her colleagues would manage the type of patient described by Newton and Stephenson. They would be given 20-30 min of physiotherapy initially followed by supervised physiotherapy three times a day. She estimates that 30 ml of sputum would be produced initially and on average at least 60 ml in 24 h. University Department of Medicine,
1. St John, E.G. Am. J. Roent. 1956, 76, 315. 2. Bell, R. S., Loop, J. W. New Engl. J. Med. 1971, 284, 236. 3. Harwood-Nash, D. C., Hendrick, E. B., Hudson, A. R.
101, 151. 4. Roberts, F., Shopfner, C. H. Am. J. Roent. 1972, 114, 230. 5. Jergens, M. E., and others. West. J. Med. 1977, 127, 1. 6. Jennett, B. Br. med. J. 1978, i, 1601.
Foresterhill, Aberdeen AB9 2ZD
K. N. V. PALMER
Radiology, 1971, 7. Bunker, J. P. (editor) Costs, Risks, and Benefits of Surgery. New York, 1977. 8 Cochrane, G. M., Webber, B. A., Clarke, S. W. Br. med. J. 1977, ii, 1181. 9. Rebuck, A. S., Read, J. Am. J. Med. 1971, 51, 788.
