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EPSOM SALTS FOR

HYALINE-MEMBRANE DISEASE

A NEW treatment for premature infants with hyaline-membrane disease was suggested at a meeting of theCollege of American Pathologists and the American

Society of Clinical Pathologists in Miami last month.!The work of Dr. Daniel Stowens, associate professor ofpathology in the University of Louisville, Kentucky,received wide publicity, but the full details have not yetreached us.

It seems that 28 premature infants with hyaline-membrane disease were treated successfully with hyper-tonic magnesium-sulphate enemas; all improved rapidly,and it was claimed that half the babies would have diedwithout treatment. Stowens also suggested that its earlyuse might prevent the development of the disease in

susceptible infants. The treatment is based on the view thathyaline-membrane disease is caused by increased excretionof water through the lungs owing to functional immaturityof the kidneys, and the object of the enemas is to removemeconium and then to reduce pulmonary oedema.The oedema of hyaline-membrane disease is well known:

the babies have a shiny appearance, and measurements ofleg volume compared to body-weight confirm the pro-gressive peripheral oedema of babies with respiratorydistress.2 Post mortem, there is oedema of all organs,especially the lungs and the brain. Although this can bepartly accounted for by cardiac failure, extrapolation fromthe work of McCance and Widdowson 3 on asphyxiatednewborns strongly suggests an element of renal failure.Newborn infants have difficulty in handling a solute loadand conserving base; raised levels of blood urea, potassium,and phosphorus are common in the first few days of life,and these changes are probably greater with increasingprematurity. We also know that there is a shift of waterfrom the plasma to the extravascular compartment 4;but this is normal, and studies by deuterium-oxide andbromide dilution techniques have shown no significantdifference in the body-water compartments betweennormal premature infants and those with respiratorydistress.5 This finding accords with clinical experience,for most premature infants show peripheral oedema,whether they have hyaline-membrane disease or not.

Moreover, the shifts of body-water result in a relativeincrease in the percentage of body-water, but the urinevolumes of babies with respiratory distress are often

greater than normal and the total body-water falls in thefirst twenty-four hours. In other words, the babies loseboth weight and water, but solids are burned faster thanwater is excreted.

It is hard to see how theories of hyaline-membranedisease based on the formation of pulmonary oedema canaccount for its onset from birth or the protein exudate 7which is an important feature of the membrane itself. Itnow seems certain that the disease is characterised by analteration or absence of the normal surface-active alveolar

lining,8 9 and any further elucidation of the problem must1. New York Times, Oct. 22, 1964.2. Sutherland, J. M., Oppe, T. E., Lucey, J. F., Smith, C. A. Amer. J. Dis.

Child. 1959, 98, 24.3. McCance, R. A., Widdowson, E. M. Arch. Dis. Childh. 1955, 30, 405.4. Gairdner, D., Marks, J., Roscoe, J. D., Brettel, R. O. ibid. 1958, 33, 489.5. Clapp, W. M., Butterfield, J., O’Brien, D. Pediatrics 1962, 29, 883.6. Nicopoulos, D. A., Smith, C. A. ibid. 1961, 28, 206.7. Gitlin, D., Craig, J. M. ibid. 1956, 17, 64.8. Pattle, R. E., Claireaux, A. E., Davies, P. A., Cameron, A. H. Lancet,

1962, ii, 469.9. Avery, M. E., Mead, J. Amer. J. Dis. Child. 1959, 97, 517.

stem from these findings. Treatment with magnesium-sulphate enemas is based on tenuous premises, and it is incontradiction to the good results with supportive infusionsof glucose and bicarbonate. But if magnesium-sulphateenemas are unlikely to influence the pulmonary changes,the removal of meconium may assist diaphragmaticrespiration; and an effective reduction of cerebral oedemacould well be beneficial. The treatment has the virtue of

being simple and safe, and clinical trials should quicklyestablish its value.

PARTNERSHIP-BENIGN OR MALIGNANT?" WHAT has gone wrong with general practice ? " is a

question answered in many ways of late: But Dr. Frears(p. 1114) is the first, we think, to say that a principal causeof the malaise is partnership.He regards partnership as a form of dichotomy which

should have no place in any system of medical practice-least of all in a public service. " The reason for partner-ship contract ", he argues, " is not to form group practicebut to preserve a right to appoint." That " the livingshould in this way be

" in the gift of the incumbent "-that partners should be able to make an appointment byprivate gift to a doctor they alone have chosen-is in hisopinion an anachronism. But, though he is right in

deploring the almost insuperable difficulty of changingfrom a practice in one area to a practice in another, he iswrong, we believe, in supposing that, in the days whenpractices were bought and sold, such a change was simple,and was freely and frequently made.

Dr. Frears puts forward principles which he wants re-established : full freedom for the patient to choose and tochange his doctor; no sharing of responsibility for thecare of the patient; the doctor who takes the responsibilityshould also take the fee; all appointments should be madein a manner appropriate to a public post-by an appoint-ments board. Acceptance of these principles would, heholds, make it easier for young doctors to enter practice,and for older ones to change to a different practice. Pre-

sumably they would do so by application for a practicevacancy elsewhere, and the need to back this applicationby evidence of merit would, in Dr. Frears’ view, promotegood practice, and diligence in postgraduate studies.These and many other aspects of partnership practice

would repay reconsideration, though many of them-including some that he mentions, such as mobility, andanomalies in superannuation-will be found to applyequally strongly to single-handed practice. Whether adoctor is in partnership or not, his energies and his incometend to fall in the years immediately preceding his retire-ment. For this reason alone, it was long held that noequitable superannuation scheme could be devised for anon-salaried medical service. The present arrangements,designed primarily to overcome this difficulty, have provedworkable; but they have now been in force long enough tojustify review. The fact that a general practitioner(particularly one entering partnership) now achieves some-thing approaching his maximum income quite early in hiscareer, and thereafter has little hope or incentive to dobetter, also deserves study.When Dr. Frears says that " in most walks of life a man

does not select his colleagues " he forgets, perhaps, thatthe general practitioner has always held that the inter-dependence of partners, who work together in mutualsupport throughout their professional lives, makes it

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essential for them to have an undisputed say in the choiceof a lifelong partner. But if on this and some other

points we do not agree with Dr. Frears, we shall be nonethe less glad if his forthright criticism leads to reconsidera-tion of the pros and cons of partnership practice.

ECOLOGY OF THE STAPHYLOCOCCUS

CHEMOTHERAPEUTIC achievements have controlled butnot eliminated the staphylococcus. As a natural parasiteof many mammals, it has a regular place in our environ-ment and is probably here to stay. We may thus have toregard it with understanding rather than mere disapprovaland learn afresh how to live with it, for the organism hasmoved with the times.

It is therefore interesting to find the New York Academyof Sciences discussing last month the ecology of thestaphylococcus in fundamental terms. For once, thefamiliar notes of phage-typing and drug resistance wereheard in a minor key. The major subjects were bio-chemical and experimental. J. L. Strominger, now atWisconsin, described the polymers which form the cellwall, drawing attention especially to the cross-linking ofmucopeptide chains by polyglycine bridges to build a

rigid three-dimensional lattice within which a third

ribitol-phosphate polymer, teichoic acid, plays an addi-tional role in conferring immunological specificity. It is

already known that some antibiotics, notably the peni-cillins, act specifically by preventing the incorporation ofkey components in these polymers,! but it now seems thatcertain enzymes can selectively break some of the linkagesin the lattice; one of these (lysostaphlin) may be of

promise as a chemotherapeutic agent with a higherspecificity than penicillin. In addition to its structural

role, teichoic-acid complex appears, from the work of PerOeding and S. I. Morse, to form an important species-specific antigen which, according to S. Mudd, may be thecombining site for phagocytosis-promoting antibody.Attempts to differentiate pathogenic from saprophytic

staphylococci are usually based on " markers " like thecoagulase-test. The inherent weakness of this kind of

classification, as well as the uncertain basis of the testitself, was demonstrated by M. Tager and Margaret C.Drummond and by A. C. Baird-Parker, while morerealistic markers (oc-toxin, enterotoxin, leucocidin) receivedattention from A. W. Bernheimer, E. P. Casman, andA. M. Woodin, among others. The conference chairman,Prof. D. Ivler, of the University of Southern California,showed that the main differences between virulent andavirulent staphylococci were metabolic, depending uponendogenous respiration and aminoacid transport. Thisdifference overrides conventional " markers " of patho-genicity, for coagulase-negative strains from cases ofendocarditis show the same metabolic patterns as

coagulase-positive strains from the usual lesions. The roleof coagulase-negative strains in endocarditis, and theirincreasing frequency as active infectors in patients withvascular prosthesis, was also discussed; and a group fromDetroit (E. L. Quinn, F. Cox, and M. Fisher) drew atten-tion to the virulence of these organisms in such casesthough, again, the conventional

" markers " of patho-genicity were usually absent. There is clearly room forrethinking as well as reclassification in this segment ofbacteriology. ,

The morphology of the organism is also under energeticexamination-and revision. L-phase variants, lacking the

1. Park, J. T., Strominger, J. L. Science, 1957, 125, 99.

rigid mucopeptide cell wall, can be produced by trans-ferring cells from normal colonies into enriched mediaof higher osmolarity. Describing the properties of thesevariants, B. M. Kagan showed that viable elements couldpass through membranes with a pore-size of 0-05 [4 andwithstand extremely high concentrations of bactericidalantibiotics such as penicillin. It has also been shown

recently 2 that L-forms together with distinctive granularvariants are readily formed from strains with natural resis-tance to methicillin. The question, therefore, arises as towhether these protoplastic forms are elemental and arepresent in suppressed or latent infections. If this is so-and there is no proof as yet-a new chapter and a newdimension will be opened in microbiology.Among the other contributions to the meeting, the

continuing efforts of R. P. Novick on the extra-chromo-somal determinant of penicillinase production, and of ateam working in New York and Dallas on the deliberatecolonisation of infants and adults with competitivestaphylococci of low virulence, will obviously attract

further attention.

BIRTH CONTROL FOR PROBLEM PARENTS

IN Britain, where we are told society is affluent, thereare many families who fall far short of sharing in thisaffluence. They have been called " problem families ",and the " problem parents " among them need help in allsorts of ways. One of their most pressing needs is aneffective means of family limitation, yet they often showa complete lack of interest in contraception.

In Southampton, since these parents would not or couldnot attend family-planning clinics, Dr. Dorothy Morgan,of the city’s central health clinic, decided in 1961 to

attempt to provide a domiciliary birth-control service.With a grant from the Marie Stopes Memorial Fund ofthe Eugenics Society, Dr. Morgan, a nurse, a secretary,and two male social workers went to work in the poorestquarters of Southampton. The families they visited livedeither in rehabilitation centres (flats where families aresent after eviction from council or private housing) or insubstandard tenement accommodation. In three years(by August, 1964) Dr. Morgan was successful in convert-ing 150 families to the use of contraceptives. This was noeasy achievement, for, suspicious of strangers, thesefamilies did not take kindly to anyone who seemedconnected with officialdom. Their living conditions wereextremely poor, with untidy, ill-kept homes and raggedchildren, and they resented others becoming aware of this.Tact and perseverance won them over in the end, andacceptance in one home helped in the neighbourhoodgenerally. Birth control was discussed at a joint interviewwith man and wife. It was important not to foster the ideathat birth control was the concern of only one partner; andthe joint interview emphasised that it should be a shareddecision.

Until January, 1963, only the mechanical forms ofcontraception could be offered; but oral contraceptivetablets are now by far the most acceptable form of birthcontrol among these families (68 out of the 150), mainlybecause their use demands the least effort. Next in

popularity is the occlusive cap used with contraceptivecream (31 women), while condoms come a poor third(17 men). Thus, 116 (76%) of the 150 families are using2. Kagan, B. M., Martin, E. R., Stewart, G. T. Nature, Lond. 1964, 203,

1031.