487

The source of lead in the first case is not yet definitelyestablished, but the second child had ingested lead fromthe old and crumbling paintwork of an outside balcony.The lead content of the paint was 54% (calculated asthe metal).There is clearly a need for more safeguards against

this danger than exist at present.

M. B. MORRIS.Whittington Hospital,London, N.19.

ACTION OF ANTIBIOTICS

DERKICK ROWLEY.Wright-Fleming Institute of

Microbiology, St. Mary’s HospitalMedical School, London, W. 2.

SIR,—I consider it dangerous to let your interestingleading article of Aug. 23 pass without comment,especially in so far as penicillin action is concerned.That penicillin affects the assimilation of glutamic

acid is beyond doubt, but it is equally beyond doubtthat*death of the cell does not come about because it hasbeen deprived of the vital preformed glutamic acid.Many penicillin-sensitive staphylococci will grow withoutadded glutamic acid and a Bacillus subtilis has beendescribed which is extremely sensitive to penicillin, evenwhen growing on a medium composed of inorganic saltsand glucose only. Thus, we can have both penicillin-sensitive and penicillin-resistant organisms which are

nutritionally independent of preformed glutamic acidor of any other amino acid. Dr. E. F. Gale, who has donesuch excellent work on this subject, has wisely avoidedjumping to the easy conclusions which you expound.In spite of the tremendous amount of work done in thelast few years on the mode of action of antibiotics, weare far from understanding how any of them works.

ATTENDANCE AT BOXING CONTESTS

J. L. BLONSTEINHon. Medical Officer.

London Amateur Boxing Association,69, Victoria Street, London, S.W.1.

SIR,—We are anxious to obtain the voluntary servicesof medical men to attend amateur boxing shows inLondon and the suburbs during the coming autumnand winter.

The shows usually take place in the evening, and the dutiesconsist in examining the contestants (total time ½—3/4 hour)and being available or on call for any serious injuries, whichare usually very few. The only reward we can offer is a goodboxing show and a convivial evening.Medical officers will have the satisfaction of knowing that

they are assisting to foster a high physical and moral standardin the health of the nation’s youth.

Will doctors who are interested please write to me ?

BLOOD-PRESSURE ESTIMATIONS IN CHILDREN

G. E. BREEN.South Middlesex Hospital,

Isleworth.

SIR,—Your explanation (Aug. 16) that you were

referring to research conditions in your leading article onthe treatment of bacterial meningitis disposes at onceof two of my objections to your proposed scheme ofhiood-pressure estimations—namely, that child mano-meter cuffs are not generally available, and that thesuggested procedure would prove appallingly time-

consuming. But not, I think, of my third, and perhapsmost important, objection-that in most cases even

when a reading has been obtained its value is doubtful.The Waterhouse-Friderichsen syndrome occurs pre-

dominantly in young children, often very young children.Though desperately ill they are not, unless in the terminalstages, inert ; on the contrary they are restless andresistive. They struggle against the manometer cuffand have to be firmly held. Of what value are readingsobtained under such restraint And are we justified inprovoking these patients to expend their diminishingnerves of strength for the sake of such equivocalfindings t By all means let us have as many accurateblood-pressure estimations as we can in catiperativepatients; I agree that they afford valuable confirma-

tory evidence in diagnosis. But diagnosis is not so

difficult as suggested, and, with respect, has seldom tobe made from other very severe forms of ordinarymeningitis, for in fact there is little similarity betweenthe two conditions. The crucial feature of the Water-house-Friderichsen syndrome is that signs of meningitisare either extremely slight or, more usually, absent, andthe conditions usually suggested to the clinician are

malignant purpura or pneumonia.Perhaps I can make my position clearer if I say that in

my view any patient who presents with collapse anda purpuric or ecchymotic (not petechial) rash, particularlyif there is livid cyanosis and perhaps polypnœa, shouldhave a lumbar puncture. If this reveals an opalescentor turbid fluid under increased pressure, cortisone andsulphonamides should be given without delay; forthis is one of the most acute emergencies in medicine-one has seen a patient die within 12 hours of taking ill.The amount of cortisone required is relatively negligible.I agree that its value in this syndrome should be mostcarefully assessed ; but I submit that this has alreadybeen shown to be considerable ; and if we are to waituntil correct blood-pressure estimations have been made,then I submit, Sir, that many lives will be lost thatmight otherwise he saved.

1. Neuhauser, E. B. D.. Berenberg. W. Radiology, 1947, 48, 480.2. Glanzmann, E. Einführung in die Kinderheilkunde. Vienna,

1949; p. 220.

CAROB FLOUR IN FUNCTIONAL VOMITING OFINFANTS

SIR,—Most babies who frequently vomit or regurgitatetheir food are just mild " posseters," but a few belongto the more serious and even alarming class of " habitualvomiters." These babies may reject their food any timewithin an hour of feeding. The trouble may start verysoon after birth in either breast- or bottle-fed children.When an organic cause has been excluded, the diagnosisof " habitual vomiting " may reasonably be made. Thisis a functional disturbance of ingestion which includescardio-oesophageal relaxation.1 The problem of gettingthe baby to retain its food must then be tackled.Most infants come to no harm from occasional or even

quite regular vomiting, but the baby whose weight staysthe same or actually falls is in danger, and under-nourishment may lead to dehydration and atrophy.And in spite of this the infant is hungry, alert, and avidfor food which it cannot hold.The usual treatment is to thicken the food by adding,

say, wheat flour or arrowroot to the milk formula or tothe expressed breast-milk, thereby increasing the viscosityof the milk and helping to keep it in the stomach.Phenobarbitone may also be given before each feed.These measures usually work in the simpler cases. Fine-oatmeal gruel and pureed potato made with milk aresometimes used, or the consistence of the feed may besuitably altered by using powdered or condensed milks,extra fluid being given as water between feeds. What-ever method is used there is an important disadvantage--the formula is poorly balanced for the infant’s nutritionalneeds, and growth may be affected.

It was with much relief that I heard of Professor

Lelong’s work in Paris on this problem. All degrees ofpersistent functional emesis in infants were treated withmilk thickened by the addition of carob flour, a powderextracted from the seed of the Levantine carob tree.Information about this legume, Ceratonia siliqua (Linne),is given by Glanzmann.2 This flour was prepared forProfessor Lelong’s trials by the Nestlé Company ofSwitzerland, and has proved indispensable. Its virtuesare that it has no flavour, it thickens the milk withoutlessening its digestibility or changing its nutritive value,and it is completely inert and neutral. But it does alter