LETFERS TO THE EDITOR 859
being taken not to spread it too thinly.
Fix-ation is then accomplished by consecutive
10-second immersions into a series of dilu-tions of a standard fixative consisting of
al-Coilol (6 volumes), acetic acid (2 volumes),
and formalin (1 volume). The dilutions
em-ployed are 1 : 2000, 1 : 1000, 1 :50 and finally,
full-strength fixative. The slide is then
rinsed twice in distilled water, and allowed
to dry in air either warmed or at room
temperature.
Three to four drops of 2.5% Orcein
Ace-tate’ are placed on the fixed preparation,
wilich is covered with a coverslip, the
ex-cess stain being removed by filter paper
ap-plied to the edges of the coverslip. The
preparation can be sealed temporarily with
Kronig’s cement, or made permanent with
balsam, as described elsewhere.4 The entire
procedure can be completed within 5 to 10
minutes. As with the original technique, the
presence of tile chromatin body in 20 to 30%
of cells is indicative of a positive test. A. ROBINSON, M.D.
Department of Biophysics
and Pediatrics University of Colorado
Medical Center Denver, Colorado
References
1. Moore, K. L., and Barr, M. L. : Smears from
tile oral mucosa in the determination of
chromosomal sex. Lancet, 2:56, 1955.
2. Tjio,
J.
H., Puck, T. T., and Robinson, A.: The somatic chromosomal constitution of some human subjects with genetic defects.Proc. Nat. Acad. Sc., 45:1008, 1959.
3. Puck, T. 1., Cieciura, S.
J.,
and Robinson A.: Genetics of somatic mammalian cells. III.J.
Exper. Med., 108:945, 1958.4. Tjio,
J.
H., and Puck, T. T. : Genetics ofso-matic nlammalian cells. II.
J.
Exper. Med., 108:259, 1958.Foreign Bodies in Puncture Wounds
Through Shoes
To mw EDITOR:
Two similar experiences in the past 2
weeks prompt this letter. The first was a
nail puncture of the foot, and the child
stated definitely that the nail penetrated at
least three-fourths of an inch through his
“shoe” and into the foot. The wound was
cleaned and inspected in the usual manner,
soaks were advised and tetanus
adminis-tered. Two days later the foot was swollen,
and examination revealed a red foreign
body at the entrance to the wound. It was
removed easily with a forceps and was
found to be a small cone-shaped piece of
sponge rubber. Only then did I learn his
“shoe” had been an oriental type thong
sandal, the type which is very popular now.
A few days later another patient with a
nail wound (through a thong sandal) came
into the office. An obvious piece of the
sponge was visible and another piece was
found deeper in the wound.
This may be coincidence, but has alerted
me to check these injuries more closely for
a foreign body. Possibly other pediatricians have had similar experiences.
J
OSEPH L. RosrmzwEIG, M.D.Hot Springs, Arkansas
A Challenge to Practitioners
To ThE EDITOR:
The recent series of communications
re-lating to the practice of pediatrics has stated the problems more clearly than the solutions
to these problems. In an Editorial
(PimI-ATRIcS, 23 : 1038, 1959), a statement was made
which summarized the problem of
“discon-tent with the discrepancy between tile
em-phasis in pediatric training and the nature
of experiences encountered in practice” and
suggested that “one type of training is not
apt to be equally suitable for all the broad
groups of pediatricians (academicians and
consultants, general practitioners, and
pub-lic health administrators).” Thus, a large
part of the burden of solving the problem
of the practitioner was placed on tile shoui-dens of the pediatric educators. Tilere can be
no question that pediatric educators can
and will face up to this responsibility, but
are there not other means by which tile
tomor-860 LETFERS TO THE EDITOR
row might improve his work?
We ask the pediatrician to practice
corn-prehensive pediatrics, including mental
hy-giene, and to give advice for a variety of
social problems-child adoptions, school
problems, problems of social
adjustment-which must be considered paramedical since
they do not involve primarily medical
prob-lems of diagnosis, treatment, and
preven-tion of disease. Yet, it is difficult to ask a
person trained through college and first 2
years of medical school in basic science and
scientific methodology, through medical
school and 3 years of postmedical school
training in disease and its ramifications to
become involved in areas where he cannot
use this immense endowment. The
pediatri-cian may by inclination and personality be
interested in some of these aspects of
corn-prehensive child care and should be, but he
is not particularly expert in these fields. His ability to contribute in these areas is largely related to his position as a physician and his role as a most important family adviser.
Certainly, more comprehensive pediatrics
should be practiced than the “shot and
for-mula” type. However, should the
pediatri-cian whose entire medical background (and
oftentimes temperament) may not suit him
for giving expert advice in schooling
prob-lems, adoption procedures and problems of
social adjustment be the one to fill this
vacuum? Cannot many of these questions be
more effectively answered by social workers,
guidance counselors, ministers, lawyers and
otiler personnel?
Has the practicing pediatrician
com-pletely mined the medical aspects of his
practice so that he must now turn to the
paramedical?
I do not believe he has exhausted the
medical potentialities and I do believe that
pediatrics should turn toward improving
this aspect rather than looking for work in
other areas. Most pediatricians would be
happier if their work load reverted from its
present preponderance of well infants, often
with trivial problems, to a concentration on
more children with serious medical
prob-lems. This might be accomplished in several ways.
1. Development of a vertical subspecialty.
This has almost always proved satisfying
when done in a realistic way with attention
to economic realities. Obviously, a
pediatni-cian practicing in a small community
can-not practice a subspecialty of cardiology
unless he has a hospital affiliation with a
large institution. However, a subspecialty
in allergy or mental hygiene might be
worked out even in small communities. ‘It should be stated that specialists from internal medicine have no reservations about their abilities to handle children with car-diac, allergic or neurologic problems. These vigorous people are extending their interest
down into the childhood period and offer a
considerable threat of the elimination of the pediatrician as a specialist.
The attitude expressed by the editor of
PEDIATRICS, “It may be appealing to dream
of acquiring a profound command of the
many aspects of the subject-hematology,
endocrinology, cardiology, child guidance,
etc.-but in fact no one exhibits real
corn-petency in more than one small sphere of
the current knowledge. We may as well
face it, there will not be enough Leonardos to form an Academy of genuine ‘consultant’
pediatricians. The inevitable trend will be
an increasing dependence on those who gain
real proficiency in limited fields for
de-finitive consultation.”, expresses a defeatist
point of view which is not in keeping with
a practicing profession that insofar as
pos-sible should be attempting to preserve its
intellectually stimulating areas of disease.
I would venture to maintain that the
intelligent pediatrician, given the proper
stimuli and freed to an extent from the load
of routine patient care, could keep up more
readily with the fields of hematology,
endo-cninology, cardiology, infectious disease and
para-LETTERS TO THE EDITOR 861
medicine. Certainly, he could develop
in-terests in at least one of these subspecialties
and become masterful enough to keep up
with its literature. The pediatrician
in-terested in one of these subspecialties such
as allergy would not be compelled to
aban-don his patients when they reach the age of
12 or 21 years nor would he have to limit
his new referrals to children if this were his wish.
Many pediatricians could acquire enough
knowledge in bacteriology to treat
infec-tious diseases more scientifically. Those
pediatricians who have developed their own
bacteriology laboratory have often been far
more effective in the treatment of children and have not often subjected their patients
to unnecessary, potentially allergenic,
medi-cations. A pediatrician who is a good
bac-teriologist may be very much in demand
by his medical colleagues.
2. Broadening of preventative pediatrics to include advice on genetically-determined
d!seases. Perhaps the most important recent
discovery in medicine has been the
relation-ship of genetic factors to many of the major
disorders. Their importance was illustrated
i)y the concentration of a large part of a
recent conference of teachers of cardiology
on the probable major role of genetic
fac-tors in all of the major forms of heart
dis-ease, including congenital heart disease,
rheumatic fever, hypertension and coronary
thrombosis. In a discussion of these subjects
by Drs. Curt Stern and Victor McKusick
nearly all of the examples illustrating the
genetic factors were studies of children. There is need for a vast expansion in
knowl-edge of preventative medicine, and the
pedi-atrician may be brought into contact with
many of the major problems of adult
medi-cine. Advice concerning dietary habits,
choice of occupation, and a lifetime
pro-gram of medical care will be defined far
more precisely than at present, depending
upon the family history encountered.
Coun-selling of the parents concerning the desir-ability of having more children when a pilot
case of a genetically-determined disorder
occurs must be grounded on a sound
knowl-edge of the genetic probabilities. A large
part of this aspect of preventative medicine
will be handled by the pediatrician and
should be intellectually stimulating as well as economically remunerable.
3. Narrowing the widening chasm be-tween the practitioner and the specialist.
Initiative should be taken by individual
pediatricians and the Academy to attempt
to narrow this chasm. Since most pediatric
specialists are now employed in medical
teaching centers, efforts should be made to
get the practitioners back into these centers
in a systematic manner. Regional teaching
conferences, unrestricted hospital appoint-ments, closed circuit television, rotation of
medical students through pediatric
prac-tices, exchanges of personnel between
pni-vate practice and medical center work may
all be used more imaginatively than they
have in the past to foster closer relations
between the medical center pediatrician
and the man practicing in the community.
Joint scientific studies of important
prob-lems in medical science, where the home
en-vironment is a major factor, could be under-taken and grants for this type of work might be jointly submitted by outside practitioner and hospital specialist. This type of study would appear to be especially appropriate for evaluating the spread of infectious
dis-eases in the home, but also would he very
helpful for genetic studies, accident
pre-vention studies, and for studies relating to
mental hygiene and the sociology and
eco-nomics of medical practice.
4. Improving the status of the practicing pediatrician. The proposed program of the Academy for health education ‘is a splendid
beginning. Pediatricians have for a long
time been the most altruistic of practitioners
and because of this have lost ground in the
commercial “jungle.” They have been
pro-viding an unmatched bargain in medical
con-862 LETTERS TO THE EDITOR
freres, see fewer patients for longer periods,
charge for telephone calls that provide
medi-cal advice. If they do not think their
pa-tients can and will pay for these services
they should talk to their internist friends
(
who charge far more for the same service)and to pedodontists, orthodontists,
ortho-pedic surgeons, obstetricians, psychiatrists and others, who treat health problems of the young family.
5. Amalgamation of practices. Group
practice has usually proven stimulating and
has freed time for the general pediatric
practitioner. This has been developed
suc-cessfully in many ways and will not be
dis-cussed further except to say that it provides
an opportunity for medical interchange with
colleagues in other specialties which
usu-ally is stimulating. It may also provide a
more stable financial setting and thus allow the practitioner to take more time off to at-tend meetings and courses.
In the attempts to modify the pediatni-cian’s role to adjust to surrounding social
forces and changing medical knowledge,
the Academy should rate highly the factor
of preserving the scientific abilities of the practitioner at a high level. Fragmentation of pediatricians into three
groups-acadelni-cians, general practitioners, and public
health administrators-would have the
in-evitable result of further devaluating the
general practitioner of pediatrics perhaps to the point of extinction. The quality of
medi-cine in America has ‘been kept high among
practitioners because they have received a
competitive education similar to that of
their medical center colleagues. Pediatrics should not sacrifice the identity of interest
of practitioner and specialist in the medical
center. The field of internal medicine has
effectively maintained this relationship.
It is hoped that these observations by a
specialist in a medical center who has prac-ticed general pediatrics may be considered
constructive. It would seem wise at this
time that the Academy appoint a committee to study the practice of pediatrics in detail and to investigate the ways by which
pedia-tnics can remain a most rewarding specialty.
