of 1 /1
188 which it has differentiated convincingly between fact and widespread supposition. In this way it has made a valuable contribution to the body of knowledge built up from sociopsychological field studies. But this is only a beginning. As the scope of television develops, so will there be increasing need to keep track of its influence. Future studies could with confidence be based on the present model. Essentially, this report testifies to the robust resilience of children, to their inherent capacity to adapt themselves to altered condi- tions and new experiences while retaining their emotional balance. The implications are encouraging. Annotations SUBACUTE BACTERIAL ENDOCARDITIS IN THE ELDERLY SUBACUTE bacterial endocarditis is usually pictured as a disease of young people, who have fever, clubbing of the fingers, splenomegaly, and perhaps emboli, and who give a history of rheumatic heart-disease. This is the chief reason why it is so often overlooked in older patients. Contrary to earlier reports 1 2 that it was rare in the elderly, Anderson and Staffurth found that nearly a fifth of 76 patients with bacterial endocarditis were over 60; which agrees closely with Wedgwood’s 4 figures of 17% of 65 cases. Anderson and Staffurth cited the Registrar General’s Statistical Review for 1953, which showed that 28% of all deaths from bacterial endocarditis were of patients over 60. According to Friedberg,5 in the elderly the picture may be atypical and the disease is usually overlooked. In addition to any failure among this age-group to respond so readily to treatment due to infection with organisms other than Streptococcus viridans, missed or late diagnosis must be an important reason for this high proportion of deaths. In Staffurth and Anderson’s series the history was usually far longer and the onset more insidious than in younger patients: occasionally the disease conformed to the textbooks, but often a fever and murmur were the only signs; emboli were uncommon, finger-clubbing was present in only half the patients and a palpable spleen in even less. Only 2 of their 14 elderly patients were known previously to have a valve lesion, and in the majority of the remainder the murmur could easily have been termed insignificant by the unwary. Gleckler 6 has again drawn attention to the unusual presentation of bacterial endocarditis in older persons. Only 3 of his 10 patients showed the classical picture; 3 presented with psychosis and fever, 2 with anorexia and abdominal symptoms, 1 with urasmia, and 1 with cerebral hxmorrhage following septic embolism. A murmur and fever were present in all, though in 1 the murmur was trivial. Like syphilis, bacterial endocarditis can, it seems, be a great mimic, at least in the elderly-suggesting such diagnoses as carcinomatosis, cerebrovascular disease, or perhaps renal disorder. It is as well to have the possibility constantly in mind in dealing with a difficult diagnostic problem. 1. Willius, F. A. Proc. Mayo Clin. 1940, 15, 270. 2. Cates, J., Christie, R. V. Quart. J. Med. 1951, 20, 93. 3. Anderson, H. J., Staffurth, J. S. Lancet, 1955, ii, 1055. 4. Wedgwood, J. ibid. p. 1058. 5. Friedberg, C. K. Diseases of the Heart. Philadelphia, 1956. 6. Gleckler, W. J. Arch. intern. Med. 1958, 102, 761. THE CONTAMINATED CARAFE "GROSSLY unhygienic conditions were described in two-thirds of the carafes. Dead, partially decomposed insects were frequently seen. The walls of some carafes were slimy; gelatinous islands of algx and fungi floated in others." This is not a novelist’s description of the dining- room of the Grande Hotel de Pondicherry et des Commis Voyageurs in some up-country town in Indochina but of the bedside water-containers in 24 Boston hospitals. A recent inquiry—originating it seems from the complaints of the patients-discloses a sorry state.1 The water-supply of Boston is above reproach, but 22% of the bedside carafes contained coliform bacilli and 69% staphylococci (which included some of type 80/81). The causes were various. Sucking the contents through a straw (now called a " drinking-tube ") allows saliva to flow back into the water. Inverting the drinking-glass over the neck of the carafe has the same effect. The shape typical of the carafe with a long narrow neck makes thorough cleaning difficult. The carafes were not always returned to the right bedside when they had been refilled and were seldom if ever sterilised. And there are many other ways in which the water might be contaminated. To provide the patient with something to drink at his leisure is obviously humane, and some are under orders to drink all they can. Despite the finding of pathogenic staphylococci the dangers (so far) appear to be theoretical, but this paper makes it clear that every hospital should devote some thought to this problem. Our hospitals are cooler and our demands for water less acute than in the U.S.A. Some of our hospitals provide water only when the patient asks for it, and some give fruit drinks which are not allowed to linger indefinitely at the bedside. But the carafe might well be replaced by a small jug-cheaper, easier to pour and to clean. It is probably wiser to refill it often than to provide a cover. The drinking-vessel should be washed at least twice a day with the other domestic’crockery. Whether carafe and glass should be sterilised is open to question, except where the patient has such a disease as enteric fever. Some reports have suggested that all ward crockery should be disinfected after use, but the cost is probably out of relation to the advantages. There is, however, much to be said for sterilising-chemically or by heat-the bedside carafe and glass when the patient leaves hospital, and this should not be too difficult. In general it would be better to insist on a standard of cleanliness which will satisfy the good housewife-and that is hard enough to accomplish, as we all know. WHIPLASH INJURY THE term " whiplash injury " has been applied to the type of lesion of the neck which is especially likely to arise from car collisions. If a man is sitting in a car which is run into from behind, his body continues to move forward while his head, being hinged at the neck, may go suddenly backwards with acute hyperextension of the cervical spine; the head then often going forward again with acute flexion of the neck. In some cases subsequent radiographs may show injury to the bones or joints, but usually no definite abnormality is seen. Possibly there is momentary posterior subluxation with transitory narrowing of the inter- vertebral foramina and damage to nerve-roots. Seletz 2 suggests that damage to the spinal accessory nerve- especially traction injury of its intraspinal filaments of 1. Walter, C. W., Rubenstein, A. D., Kundsin, Ruth B., Shilkret, M. A. New Eng. J. Med. 1958, 259, 1198. 2. Seletz. E. J. Amer. med. Ass. 1958, 168, 1750.

THE CONTAMINATED CARAFE

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188

which it has differentiated convincingly between factand widespread supposition. In this way it has made avaluable contribution to the body of knowledge builtup from sociopsychological field studies. But this is

only a beginning. As the scope of television develops,so will there be increasing need to keep track of itsinfluence. Future studies could with confidence bebased on the present model. Essentially, this reporttestifies to the robust resilience of children, to theirinherent capacity to adapt themselves to altered condi-tions and new experiences while retaining their emotionalbalance. The implications are encouraging.

Annotations

SUBACUTE BACTERIAL ENDOCARDITIS

IN THE ELDERLY

SUBACUTE bacterial endocarditis is usually pictured asa disease of young people, who have fever, clubbing of thefingers, splenomegaly, and perhaps emboli, and who givea history of rheumatic heart-disease. This is the chiefreason why it is so often overlooked in older patients.Contrary to earlier reports 1 2 that it was rare in the

elderly, Anderson and Staffurth found that nearly afifth of 76 patients with bacterial endocarditis were over60; which agrees closely with Wedgwood’s 4 figures of17% of 65 cases. Anderson and Staffurth cited the

Registrar General’s Statistical Review for 1953, whichshowed that 28% of all deaths from bacterial endocarditiswere of patients over 60. According to Friedberg,5 in theelderly the picture may be atypical and the disease is

usually overlooked.In addition to any failure among this age-group to

respond so readily to treatment due to infection withorganisms other than Streptococcus viridans, missed orlate diagnosis must be an important reason for this highproportion of deaths. In Staffurth and Anderson’sseries the history was usually far longer and the onsetmore insidious than in younger patients: occasionally thedisease conformed to the textbooks, but often a fever andmurmur were the only signs; emboli were uncommon,finger-clubbing was present in only half the patients anda palpable spleen in even less. Only 2 of their 14 elderlypatients were known previously to have a valve lesion,and in the majority of the remainder the murmur couldeasily have been termed insignificant by the unwary.Gleckler 6 has again drawn attention to the unusual

presentation of bacterial endocarditis in older persons.Only 3 of his 10 patients showed the classical picture;3 presented with psychosis and fever, 2 with anorexiaand abdominal symptoms, 1 with urasmia, and 1 withcerebral hxmorrhage following septic embolism. Amurmur and fever were present in all, though in 1 themurmur was trivial.

Like syphilis, bacterial endocarditis can, it seems,be a great mimic, at least in the elderly-suggestingsuch diagnoses as carcinomatosis, cerebrovascular disease,or perhaps renal disorder. It is as well to have the

possibility constantly in mind in dealing with a difficultdiagnostic problem.

1. Willius, F. A. Proc. Mayo Clin. 1940, 15, 270.2. Cates, J., Christie, R. V. Quart. J. Med. 1951, 20, 93.3. Anderson, H. J., Staffurth, J. S. Lancet, 1955, ii, 1055.4. Wedgwood, J. ibid. p. 1058.5. Friedberg, C. K. Diseases of the Heart. Philadelphia, 1956.6. Gleckler, W. J. Arch. intern. Med. 1958, 102, 761.

THE CONTAMINATED CARAFE

"GROSSLY unhygienic conditions were described intwo-thirds of the carafes. Dead, partially decomposedinsects were frequently seen. The walls of some carafeswere slimy; gelatinous islands of algx and fungi floated inothers." This is not a novelist’s description of the dining-room of the Grande Hotel de Pondicherry et des CommisVoyageurs in some up-country town in Indochina but ofthe bedside water-containers in 24 Boston hospitals. Arecent inquiry—originating it seems from the complaintsof the patients-discloses a sorry state.1 The water-supplyof Boston is above reproach, but 22% of the bedsidecarafes contained coliform bacilli and 69% staphylococci(which included some of type 80/81). The causes werevarious. Sucking the contents through a straw (now calleda

" drinking-tube ") allows saliva to flow back into thewater. Inverting the drinking-glass over the neck of thecarafe has the same effect. The shape typical of the carafewith a long narrow neck makes thorough cleaning difficult.The carafes were not always returned to the right bedsidewhen they had been refilled and were seldom if eversterilised. And there are many other ways in which thewater might be contaminated.To provide the patient with something to drink at his

leisure is obviously humane, and some are under orders todrink all they can. Despite the finding of pathogenicstaphylococci the dangers (so far) appear to be theoretical,but this paper makes it clear that every hospital shoulddevote some thought to this problem. Our hospitals arecooler and our demands for water less acute than in theU.S.A. Some of our hospitals provide water only whenthe patient asks for it, and some give fruit drinks whichare not allowed to linger indefinitely at the bedside. Butthe carafe might well be replaced by a small jug-cheaper,easier to pour and to clean. It is probably wiser to

refill it often than to provide a cover. The drinking-vesselshould be washed at least twice a day with the otherdomestic’crockery. Whether carafe and glass should besterilised is open to question, except where the patienthas such a disease as enteric fever. Some reportshave suggested that all ward crockery should bedisinfected after use, but the cost is probably out ofrelation to the advantages. There is, however, much to besaid for sterilising-chemically or by heat-the bedsidecarafe and glass when the patient leaves hospital, and thisshould not be too difficult. In general it would be betterto insist on a standard of cleanliness which will satisfy thegood housewife-and that is hard enough to accomplish,as we all know.

WHIPLASH INJURY

THE term " whiplash injury " has been applied to thetype of lesion of the neck which is especially likely to arisefrom car collisions. If a man is sitting in a car which isrun into from behind, his body continues to move forwardwhile his head, being hinged at the neck, may go suddenlybackwards with acute hyperextension of the cervical spine;the head then often going forward again with acute flexionof the neck. In some cases subsequent radiographs mayshow injury to the bones or joints, but usually no definiteabnormality is seen. Possibly there is momentary posteriorsubluxation with transitory narrowing of the inter-vertebral foramina and damage to nerve-roots. Seletz 2

suggests that damage to the spinal accessory nerve-

especially traction injury of its intraspinal filaments of1. Walter, C. W., Rubenstein, A. D., Kundsin, Ruth B., Shilkret, M. A.

New Eng. J. Med. 1958, 259, 1198.2. Seletz. E. J. Amer. med. Ass. 1958, 168, 1750.