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after breech or transverse presentation. Duringvaginal breech birth the base of the skull may undergomechanical distortion, which damages the pituitarystalk and might lead to partial or completeinterruption of the neurohumoral connectionsbetween hypothalamus and adenohypophysis.Studies with modem imaging techniques seem tosupport this view.

8

The dwarfism is due to a lack of growth hormonesecretion, alone or as part of multiple pituitaryhormone deficiency, when there may also beinsufficient secretion of sex hormones, which canaffect libido, sexual potency, and fertility. In view ofRichard’s alleged offspring, isolated growth hormonedeficiency seems the more likely diagnosis.But was Richard the tyrant who engineered the

murder of his nephews in the Tower of London in1483? Jack Leslau of the Society of the friends ofThomas More (The Times, August 13, p 14) thinksnot. His theory is that the two princes were smuggledout to take their place in the world as Sir EdwardGuildford (Edward V) and Dr John Clement

(Richard of York), who became president of theCollege of Physicians. Clement is buried at Mecklemin Belgium; the whereabouts of Guildford’s remains isuncertain, but his daughter’s body resides at ChelseaOld Church in London and Edward IV’s remains areat Windsor. The tombs might yield samples suitablefor DNA analysis to prove Leslau’s point, butecclesiastical authorities are not persuaded.

1. Kendall PM. Richard the Third. London: Sphere, 1973: 28.2. Nicoll A, Nicoll J. Holinshed’s chronicle as used in Shakespeare’s plays.

London: Dent, 1927.3. Rhodes P. Physical deformity of Richard III. Br Med J 1977; ii: 1650-52.4. Van der Werff ten Bosch JJ. Richard III, a pituitary dwarf? In: Slob AK,

Baum MJ, eds. Psychoneuroendocrinology of growth and

development. Bussum: Medicom Europe, 1990: 31-36.5. Rona RJ, Tanner JM. Aetiology of idiopathic growth hormone deficiency

in England and Wales. Arch Dis Child 1977; 52: 197-208.6. Steendijk R. Diagnostic and aetiologic features of idiopathic and

symptomatic growth hormone deficiency in the Netherlands. HelvPaediat Acta 1980; 35: 129-39.

7. Shizume K, Harada Y, Ibayashi H, et al. Survey studies on pituitarydiseases in Japan. Endocrinol Jpn 1977; 24: 139-47.

8. Van der Werff ten Bosch JJ, Bot A. Growth of males with idiopathichypopituitarism without growth hormone treatment. Clin Endocrinol1990; 32: 707-17.

Infection under the microscopeFifty years ago The Lancet published the results of

Florey’s pioneering study on the systemic use ofpenicillin to treat infection 1-the antibiotic revolutionhad begun. Nevertheless, the microbes not onlystubbornly refuse to go away but also seem endlesslydetermined to demonstrate their astonishingversatility. Modem medicine, meanwhile, continuesto provide an increasing supply of patientscompromised by age, disease, drugs, and biopolymerswho may succumb to microorganisms conventionallyregarded as innocuous. "New" microbial diseasescontinue to appear and some, like AIDS, bring withthem diverse and unfamiliar opportunist organismsthat present considerable therapeutic difficulties.

Safe and effective antimicrobial agents have

proliferated and treatment of infection with theformidable resources of antimicrobial chemotherapythat are now available seems seductively simple. Sinceuse of these drugs forms part of every doctor’s

training, and since infections are encountered in everymedical and surgical specialty, the need for infectiousdisease physicians has been questioned, while medicalmicrobiologists are sometimes seen as eccentric

colleagues needed only to explore and explain thearcane lore of the agar plate.A group from Northwick Park Hospital, London,

have set out to investigate the validity of this view byassessing the value of an infection consultation servicewhich combines the skills of the department ofmedical microbiology and those of the regionalinfectious disease unit. 1,3 The team were givenunimpeded access to all patients in the hospital, soboth solicited and unsolicited consultations could beevaluated. In assessing their impact they consideredwhether the consultations had helped to achieve thecorrect diagnosis and whether the advice given (ifheeded) influenced the outcome in infected patients.Advice from team members on diagnosis or

investigations contributed to the right conclusion inabout a third of consultations. Therapy that hadalready been instituted at the time of the consultationwas judged to be suboptimum for various reasons in41 % of infected patients, predominantly those onsurgical units. Under-investigation of patients (in thejudgment of the infection experts) was also common,especially within medical specialties. Advice was

nearly always heeded, at least in part, and it was notpossible to establish the effect of this on outcome. Theimpact of the consultation service seemed to be

greatest when the team had acted on their own

initiative-eg, when following up laboratory results,or when alerted by clinical details on request forms.

Although there is much room for debate as to whatis appropriate in the investigation and management ofindividual patients, the Northwick Park experiencethat shows diagnosis and management of infection canbenefit from the input of specialists. Medical

microbiologists will not be surprised at this conclusionand will point out, with much justification, that theyhave provided just such a consultation service

throughout the hospital system for very many years.4 4This is manifestly true, and doctors in this specialtyrightly resent suggestions that they do not pull theirclinical weight. However, their role differs from, andis fully compatible with, that of consultants ininfectious diseases, who provide a valuable function inthe day-to-day management of infected patients.

There are encouraging signs that infection in

hospitals is at last getting the attention that it deserves.Several reports have highlighted the need to improveinfectious disease facilities.5 In the UK, a report of thejoint working party of the Royal Colleges ofPhysicians and Pathologists has recommended thesetting up, in each health district, of teams similar to

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that already in existence in Northwick Park.6 TheGovernment’s green paper The Health of the Nationlists a reduction in hospital infection as an achievableobjective.7 Although the Government may be a recentconvert to this view, microbiologists have been awareof the need to take hospital infection seriously formany years, and have been instrumental in

establishing effective control of infection teams as wellas sensible agreed policies for the use of antibiotics fortreatment and prophylaxis-two essential elements inthe broader fight against infection beyond the needs ofthe individual infected patient. Much remains to bedone to keep the microbes in check.

1. Abraham EP, Chain E, Fletcher CM, Gardner AD, Heatley NG, FloreyHW. Further observations on penicillin. Lancet 1941; ii: 177-89.

2. Wilkins EGL, Hickey MM, Khoo S, et al. Northwick Park InfectionConsultation Service. Part I. The aims and operation of the service andthe general distribution of infection identified by the service betweenSeptember 1987 and July 1990. J Infect 1991; 23: 47-56.

3. Wilkins EGL, Hickey MM, Khoo S, et al. Northwick Park InfectionConsultation Service. Part II. Contribution of the service to patientmanagement: an analysis of results between September 1987 and July1990. J Infect 1991; 23: 57-63.

4 Association of Medical Microbiologists. Medical microbiology andcontrol of infections. An undervalued asset? Chichester: Media

Medica, 1988.5. Geddes AM. The infection physician. J R Coll Physicians Lond 1988; 22:

130-31.

6. Joint working party of the Royal College of Physicians and the RoyalCollege of Pathologists. Training in infectious diseases. London: RoyalCollege of Physicians, Royal College of Pathologists, 1990.

7. The Health of the Nation. A consultative document for health in England.London: HM Stationery Office, 1991.

Paediatrics or child health in the1990s?

Children’s departments in many medical schoolsinclude both child health and paediatrics in their title,thereby indicating concern for the whole child as wellas for the diseases that affect children. However, thegrowth of tertiary referral subspecialties may indicatea shift towards more disease orientation.

Paediatricians now face the dilemma of maintaining ahuman face and serving the immediate needs of theirpatients while allowing scientific advance.A Royal College of Physicians Conference,

summarised in a book/ examines the progress inpaediatric subspecialties and is unquestionablytertiary in flavour. Yet the selection of subjects is

idiosyncratic. Why three basic sciences (nutrition,genetics, and immunology), eight disease systems (eg,nephrology, cardiology, rheumatology), and four

chapters on specific diseases (epilepsy, cerebral palsy,diabetes, cystic fibrosis)? Community paediatrics andgeneral practice are there but not paediatricepidemiology, psychiatry, developmental paediatrics,or international child health. Growth points in

paediatric practice include gene mapping, cytokines,bone marrow transplantation, and new uses ofultrasound. Paediatric immunologists seem to claimownership of the first three of these items but they alsofeature in infectious diseases (anti-inflammatorytherapy), cystic fibrosis (the hope of gene therapy to

restore normal function), oncology (cytokines for

refractory cancer), and haematology (cytokines again,and bone marrow transplantation for aplasticanaemia). What is new that will benefit children withcommon afflictions? Learning ability at school is poorin children who have had episodes of malnutritionearly in life, and the effect on learning in children whomiss breakfast is much greater in previouslymalnourished children than in those who have beenwell nourished in the early years. These findings haveimplications for nutritional support in school.Another important message concerns cerebral palsy.Since birth asphyxia is the cause in under 10% ofcases,3 further refinements in obstetric care will makelittle difference to the overall cerebral palsy rate,though reduction in prematurity might.4 4New insulin delivery techniques have made life

easier for diabetic children; perhaps it will be possibleto identify early those who will not get complicationsso that they do not become so dependent on clinics anddoctors. Changing fashion in diagnosis is wellillustrated in asthma. Paediatricians have longabhorred the term "wheezy bronchitis", believingthat this label would encourage the prescription ofantibiotics. We now learn that wheezing followingacute bronchiolitis is unrelated to atopichypersensitivity,5 such episodes being precipitated byviral respiratory infections. "Wheezy bronchiolitis"perhaps? New types of inhaler device and the

greater involvement of parents and children in

management plans are the real areas of progress inasthma.The challenge for the next few years must be to

ensure that well-accepted advances and protocols oftherapy are put into effect and become available to allchildren. This requires close liaison between primaryand secondary care; many children never see a

paediatrician. Paediatricians have a responsibility forsetting standards in primary care and for providingtraining-a task both for subspecialists and for

generalists. The image of paediatrics conveyed by thisanthology is of a disease-oriented specialty with alesser interest in health, in primary care, and in theneeds of children. No figures on costs of treatmentsare given. There is but one therapeutic advancementioned which is costless yet highly safe andeffective-the facial application of cold water forneonatal supraventricular tachycardia. Maybe a

douche of cold water is needed to bring paediatriciansback to their roots-the child, growth and

development, and influences on health.

1. Eyre J, Boyd R, eds. Paediatric specialty practice. London: Royal Collegeof Physicians, 1991. £20 (£25 outside UK). Pp 275. ISBN 1-873240.

2. Simeon DT, Grantham-McGregor S. Effects of missing breakfast on thecognitive function of schoolchildren of differing nutritional status. AmJ Clin Nutr 1989; 49: 646-53.

3. Blair E, Stanley FJ. Intrapartum asphyxia: a rare cause of cerebral palsy.J Pediatr 1988; 112: 515-19.

4. Papiernick E, Bouyer J, Dreyfus J, et al. Prevention of preterm births; aperinatal study in Haguenan, France. Pediatrics 1985; 76: 154-58.

5. Wilson NM. Wheezy bronchitis revisited. Arch Dis Child 1989; 64:1194-99.