Klenerman, P.

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1024 S.A. MEDICAL JOURNAL 2 December 1961TABLE I. A ALYSIS OF CASES IN PRESEJ','T SERIESDurationCase Age Primary a/symptoms Neurogical status atno. (yrs.) Sex Trauma focus Myelogram before lime of operation CSF Organism End resultoperation22 M ? Rugby Positive 14 days Paraplegia Protein 300 mg. %. Sloph. Died 11 months later fromT2 Cell count not done pyogenes ascending urinary infection2 49 M Acute back f ot done 14 days Paraplegia Slaph. Recovered (95 %); slightstrain pyogenes residual weakness of ankles41 M Introduced Positive 35 days Severe degree of paresis of Staph. Slight degree of weaknessby previous l5, SI muscles and bladder and pyogenes of muscles and bladderoperation depression of sensation inS3, 4 and 54 29 M Septic Positive 16 days Root signs. Slight weakness Protein 300 mg. %. Staph. Recovered fullyfinger L2 of legs and depression of 80 cells, P> L' pyogenessensation5 48 M Furuncu- Positive 17 days Paraplegia Protein 537 mg. %. Slaph. Partial recovery; walkslosis n Globulin in excess. pyogenf!S with aid of stickOne Iymphocyte• Here P= polymorphs, L = Iymphocytesreasons should usually be carried out via the cisternalroute, do show evidence of complete obstruction (Fig. 1).The clinical syndrome in these cases tends to follow apattern in which 4 phases can be recognized: that ofspinal ache; that of root pain; that of weakness of volun-tary muscles, sphincters and sensibility; and that ofparalysis.2 During the early phases there is some degreeof pyrexia. We have noted erythema of the body belowthe level of obstruction in 4 of our 5 patients, most pro-nounced in case 1. There was none in case 5. It wouldappear that this erythema arises from an effect upon thesympathetic outflow along the nerve-roots.For various reasons the epidural phlegmon may be con-fused with the Guillain-Barre syndrome, poliomyelitis,acute disc protrusion, acute back strain, ascending paraly-sis, meningitis, perinephric or subphrenic abscess, retro-caecal appendicitis, dissecting aortic aneurysm, or pul-monary lesions.The earlier the diagnosis is made, the greater thechances of instituting drainage of the pus and consequentlythe more hopeful the chances of recovery of locomotion,sphincter control and sensation.Appropriate antibiotic treatment must accompany, butcannot replace, adequate surgical drainage. Althoughprimary closure of the surgical wound is sometimes fol-lowed by primary union, it is' preferable to leave thewound open to permit continued drainage from its depths,thus avoiding break-down and the tedious drainage ofpockets of pus under a re-entrant angle.SUMMARY AND CONCLUSIONSFive cases of pyogenic (staphylococcal) spinal epiduralabscess have been briefly described. A few series reportedby other authors and some views of these authors havebeen mentioned. The aetiology, pathology, clinical pictureand treatment of the phlegmon have been commentedupon.Pyogenic spinal epidural abscess presents an urgentproblem calling for speedy diagnosis and early surgicaldrainage.We thank Dr. H. R. J. Wannenburg. Medical Superintendentof Wentworth Hospital, and Dr. J. V. Tanchel, Medical Super-intendent of Addington Hospital, for permission to publishthese 5 cases.REFERE 'CES1. Dandy, w. E. (1926): Asch. Surg., 13, 477.2. Heusner, A. P. (1948): New Eng!. J. Med .. 239. 845.3. Hulme, A. and DOll. . M. (1954): Brit. Med. J., 1. 64.4. Dus, V. (1960): J. Neurosurg., 17, 972.5. AUbrook, D. B. (1949): Lancet, 2, 1174.6. Hutchinson, F. D. (1955): Canad. Med. Assoc. J., 70, 208.THE AFRICAN CHILDPAUll E KLE ERMAN, M.D. (EorN.), formerly, King Edward VUl Hospital, Durban"George Bernard Shaw in his wisdom said that the worstsin towards our fellow creatures is not to hate them, butto be indifferent to them. In my reflections of the pastl4 years on the life of the African child as seen at KingEdward VIII Hospital, there is much to narrate, and Iwonder whether we have not been indifferent to therequirements of this section of our community. TheAfrican population was not hospital conscious 14 yearsago, and our estimation of the medical problems wasconsequently very inadequate. During the past 8 years,and particularly in the last 3 or 4 years, the demand forhospitalization has been very intense. Let us review the.. Now Senior Physician, Paediatric Department, AddingtonHospital, Durban.general improvements in medical science during thisperiod.Many discoveries of great importance in diagnosis andtherapy have been made, e.g. the introduction of penicillinand a large group of antibiotics, many of which havereduced the hazards of a long illness and actually savedlife. Another revolution in our daily lives has been theadvent of poliomyelitis vaccine, which has receiveduniversal acclaim and has been equitably distributedthroughout our multiracial society. The repair of con-genital heart lesions, almost a forbidden territory to sur-geons some years ago, has become an essential part ofthe thoracic surgeon's duties today. The geophysical yearhas brought us into contact with the moon, and meaning-2 Desember 1961 S.A. TYDSKRIF VIR GENEESKUNDE 1025less space and ound no longer baffle modern cienti tSince the last war the welfare state of Britain ha focu edit greatest attention on tbe child and, during it mostdifficult moments, allocation of food for children waof paramount importance. Thi aspect of preventive workbas been of great value to tbe citizen of Britain.KwashiorkorWith regard to the problem of cbild care a it affecttbis country, malnutrition has been studied eriously fortbe past 14 years or so. During this time kwasbiorkor,or protein deficiency, ha reached astronomical figure,and its rise ha5 been particularly great during tbe past4 years.What are tbe factors that cau e this devastation ofthe African child? While ignorance concerning feedingundoubtedly plays a certain part, social and economiccircumstances are also responsible for the end resultswhicb manifest themselves in the disease known askwasbiorkor. Kwashiorkor exists on the wbole of theAfrican continent, and tbe original name, derived fromigeria, means the 'deposed child' because, when amother becomes pregnant again and removes her infantfrom the breast, this 'deposed child' then suffers fromprotein deficiency, since the proteins necessary for' thecbild's health are to be found in milk. Deficiency ofthese proteins causes oedema of the face, body andlimbs; enlargement of tbe liver; hair changes giving agingery or grey appearance; and denudation of tbe skinof the body, particularly in the lower abdomen andbuttocks. Eye symptoms, ranging from destruction oftbe eye to blindness; anaemia; and a host of othersymptoms are also present. In practically all these casestbe monotonous diet has consisted of mealie-mea1 por-ridge and water, samp, bread, and occasionally bean,with no other nutriment, and very little in the way offresb food.The disease presents from 6 months to 2, 3 or 4 yearsof age, and there is a general deterioration of every organof the body, resulting in an abnormal being, one whohas to be nurtured back to life at considerable expense.Tbe most important age group affected is the prescboolone, when supply of milk is absolutely essential. Thismilk: can be prescribed as skimmed-milk powder, andtbe cost of providing this food for an infant wouldTABLE I. COMPARlSO OF STATISTICS RElATING TO KWASHlORKORA!'o'D ALL OTHER FORMS OF MALNUTRITION, KrNG EDWARD vmHOSPITAL, 1955 - 1956Admissions Deaths.. { 1955 731 392Kwashiorkor1956 834 429Total 1,56- 21AU ether forms of malnutrition{1955 283 1891956 175 90Total 458 279not amount to more than 5 cent a day, wberea thee timated co t for a cbild with a full-blown kwa hiorkor,v ho require blood tran fu ion and ho pitalization,amount to R90 a month. random group of tati tifro'm King Edward III Ho pital for 195- - 1956 i givenin Table J.To deal with tbis very vexed que tion, the basic re-quirements of tbe African must be closely studied and,a Pro£. O. P. E. Horwood of the University of atal hatated, tbe African' salary must amount to at least R30a montb for a. meagre e i ten e. tatistics bow thatmany are living under the R 18 - R22 level and are unableto obtain the necessary food to keep kwa hiorkor atbay. Many of the cbildren affected with kw~shiorkorare prone to develop otber infectiou disease, such asdysentery, typhoid and tuberculosis. Tberefore it is inthe best interests of all children that tbis group is keptin a good nutritional tate, 0 tbat these diseases maynot be spread throughout tbe community. We sbouldbe cognizant of the fact that health is interdependent-one half of the community depends on the good healthof the other half for it survival. In tbe Sowh AfricanMedical Journal of 21 October 19501 I reviewed theposition of malnutrition at that time and stated that'the problem is too large for other tban governmentalcontrol, particularly in urban areas where conditionsof living among the Bantu have deteriorated owing tocongestion and increased cost of living. All our researcheswill prove fruitless unless the problem is tackled vigor-ously and energetically. The preservation of good healthmust prove less expensive than treatment of the disease.Prevention is better tban treatment'.Since 1950 the problem has increased considerably.What active steps have we taken to educate and improvethe lot of tbe African, and are we not perhaps allowingthe -position to overreach itself? Before this happenslet us adjust our thinking and invoke the aid of the3 tiers of Government, Municipal, and Provincialauthorities to help surmount the problem.May King Edward VIII Hospital in its Jubilee yearrejoice in tbe results achieved by milk as a therapeuticagent at all the oupatient clinics under its control.My tboughts end with these apt words: 'In each oneof us stands this instinct pointing with its upraisedfinger the path we have to walk: in. We may call itlove of freedom, or justice, but neither quite defines it,it is something more; it is tbe deep conviction buriedsomewhere in our nature not to be eradicated that manis a great and important thing, tbat the right of himselfand his existence is the inconte table property of allmen; and above all the conviction that not only wehave a right and are bound to preserve it for ourselve ,but that where we come in contact with other we arebound to implant' it in ~hem.REFERE CEI. Klenerm3n. P. {I 950): s. Afr. Med. J. o 24. 91.

The African child

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The African child

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