to population of 1:63 500 was a legitimate objective for planning. Our data confirm that dermatology has evolved in Ontario as largely a primary-care specialty. A study in 1970 indicated a marked maldistribution of dermatologists in Manitoba with a large concentration in Winnipeg.9 It also showed that the inhabitants of Winnipeg received per capita about six times as much of the dermatology service dollar as did Manitobans outside of Winnipeg. The most obvious reason for the concentration of neurologists in urban centres is their need for access to diagnostic facilities and neurosurgical services, but they may also choose more densely populated areas because a purely consulting practice requires a larger population base than a practice in which some patients are self-referred or have conditions at the "edges" of the specialty's scope. Dermatologists, on the other hand, are much less dependent on hospital support services, and their predominantly mixed practice, involving a good deal of primary care, can be carried out in a more sparsely populated area. It is not surprising, then, that the dermatologists we surveyed were more strongly represented than neurol-
ogists in nonmetropolitan areas; in fact, their distribution closely resembled that of the internists described in our previous paper.3 Training more dermatologists would not necessarily correct the present maldistribution, as they might continue to set up practice in large cities and include primary care in their services. However, if dermatology were restricted to being a consulting specialty there would probably be an adequate supply of dermatologic services even with the present supply of practitioners, and the competitive forces of the marketplace might force some redistribution. This strategy would be especially timely in the present era of budgetary constraints, when it is considered wasteful to train specialists to provide primary care.10'1' Although this change would require considerable administrative effort and the passage of time, there is at present no financial incentive for medical specialists in Ontario to confine themselves to an entirely referral practice. The fee schedule is the most potent device for changing the pattern of practice. References 1. National Committee on Physician Manpower: Abstract, Commentary
2.
3.
4. 5.
6. 7.
8. 9.
10. 11.
and Recommendations of the Requirements Committee Based on the Report of the Workimig Party in Neurology, Dept of National Health and Welfare, Ottawa, 1975 National Committee on Physician Manpower: Abstract, Commentary and Recommendations of the Requirements Committee Based on the Report of the Working Party in Dermatology, Dept of National Health and Welfare, Ottawa, 1975 MCCONNON JK, SHAH CP: Patterns of practice of internal medicine in Ontario. Can Med Assoc J 116: 1269, 1977 Ontario Medical Directory - 1975, College of Physicians and Surgeons of Ontario, Toronto, 1975 LERNER HJ (ed): Manpower Issues and Voluntary Regulation in the Medical Specialty System, Prodist, New York, 1974, pp 28, 87 Medical staffing in the national health service in England and Wales. Lancet 1: 944, 1970 Population and Vital Statistics for England, 1974, Dept of Health and Social Security, HMSO, London, 1974, pp 11-57 SHAH CP: The Canadian pediatrician: a dilemma in child health. Can Med Assoc J 105: 1059, 1971 Cabinet committee on health, education and social policy: White Paper on Health Policy, Govt of Manitoba, Winnipeg, 1972, p 25 HOPKINs A: Consultants' work load (C). Lamicet 1: 956, 1976 LOUDON ISL: A question of numbers. Ibid, p 736
Spontaneous peritonitis due to group B streptococci ROBERT M. BANNATYNE, MB, CH B, DIP BACT, FRCP[C]; GUSTAVO STRINGEL, MD, FRCS[C]; JAMES S. SIMPSON, MD, FRCS[G], FAGS
Spontaneous bacterial peritonitis is a well recognized complication of nephrosis.1 Pneumococci feature prominently in the etiology.2 We describe a case in which the grampositive organisms seen in the smear of the peritoneal fluid were not pneumococci. From the departments of bacteriology and surgery, the Hospital for Sick Children, Toronto Reprint requests to: Dr. Robert M. Bannatyne, Department of bacteriology, The Hospital for Sick Children, 555 University Ave., Toronto, Ont. M5G 1X8
Case report A 12-year-old girl with nephrosis awoke suddenly from her sleep screaming. Severe pain was localized in the right lower quadrant of the abdomen, was worse with movement and was accompanied by mild diarrhea and vomiting. She had had four similar but less severe episodes, of unknown cause, in the past. Her temperature was 390C. At the time of admission to hospital 3 hours after the onset of the pain she was moaning and writhing. Abdominal guarding was impressive and she had rebound tender-
442 CMA JOURNAL/AUGUST 18, 1979/VOL. 121
ness, most marked on the right side and present also on rectal examination. Her bowel sounds were nor* mal. No evidence of perforation was obtained from roentgenography of the abdomen, nor were signs of an ulcer present on a roentgenogram made after a barium swallow. The leukocyte count was 22 >< 1O./l (92% neutrophils, 7% lymphocytes and 1 % band forms). A diagnosis of primary peritonitis was thought most likely. The girl was treated initially with meperidine hydrochloride, 50 mg intramuscularly for the pain, and nasogastric suction. A solution of
dextrose and saline in a 2:1 6 hours for a further week. In the ratio supplemented with potassium year since then she has remained chloride was infused intravenously. well. A search for group B streptococci Because she had been receiving tapering prednisone therapy an in- in the girl's throat, vagina and stool itial dose of hydrocortisone sodium while she was receiving antibiotic succinate (100 mg) was given intra- therapy was unsuccessful, so that a venously along with single doses of source of the organism could not methicillin (2 g), ampicillin (2 g) be identified. and gentamicin (42 mg) to combat Discussion the possible overwhelming sepsis. Bacterial peritonitis due to group A peritoneal tap was performed. The fluid was loaded with pus cells, B streptococci has previously been all neutrophils (10 x 10./l), and recorded in persons with cirrhosis gram-positive cocci, a considerable of the liver3'4 and systemic lupus proportion of which were distorted erythematosus.5 These conditions as a result of the antibiotic therapy. share with the nephrotic syndrome Countercurrent immunoelectrophor- certain features that may explain esis on the fluid was negative for their association with group B streppneumococci. Cultures of blood, tococcal peritonitis. In each condistool and urine collected prior to the tion the patient is immunologically initiation of antibiotic therapy were compromised, whether as a result negative at this point and remained of the disease or as a result of its treatment, and is therefore less able so. Intravenous administration of to resist bacteremic infections. This chloramphenicol, 100 mg/kg daily is especially so in those with cirdivided into 6-hourly doses, was rhosis, in whom the incidence of begun (the patient's weight was bacteremia may also be increased. 32 kg). Shock, attended by a fall in In the presence of portal hypertenblood pressure, an increase in heart sion the bacteria transiently present rate, a fall in central venous pres- in the portal blood may bypass the sure and coldness of the extremities liver (the primary filter for blooddue to poor perfusion, necessitated borne organisms) via the portalan infusion of crystalloid and col- systemic collateral blood vessels and bid. The patient's condition slowly give rise to prolonged 6 improved over the next 24 hours: The factor responsible for localizathe abdominal pain lessened tion of the infection in the penslightly, the temperature began to toneum in these three conditions is fall and she became more alert. undoubtedly the presence of ascitic Two days after admission to hos- fluid, which may not be clinically pital, culture of the peritoneal fluid detectable. Finally, the source of the yielded Lancefield group B strep- organisms most often associated tococci (grouping performed using with bacterial peritonitis is generally the Rantz-Randal antigen extrac- the gastrointestinal tract,4'6 and since tion method and the gel precipitin group B streptococci commonly reaction) sensitive to penicillin. The reside in this area the occurrence of chboramphenicol therapy (eight peritonitis due to this organism in doses, for a total of 25.6 g) was persons with the nephrotic synreplaced by intravenous adminis- drome should be predictable. tration of aqueous penicillin G, 12 MU/d divided into 6-hourly References doses. After two days the dose was 1. WILFERT CM, KATZ SL: Etiology of increased to 20 MU/d. Over the bacterial sepsis in nephrotic children 1963-1967. Pediatrics 42: 840, 1968 7 days of penicillin therapy marked clinical improvement was observed: 2. KUMAR R, MCGEOWN MG, McEvov J: Primary pneumococcal peritonitis the fever disappeared, the abdomen in the nephrotic syndrome. Postgrad became soft and nontender, the leuMed 1 48: 184, 1972 kocyte count reverted to normal and 3. GINSBERG MD: Spontaneous group B streptococcal bacteremia complicating the patient's condition returned to hepatic cirrhosis: report of two cases. what it had been before the onset of I Dig Dis 13: 1065, 1968 peritonitis. She was discharged from 4. Am WEINSTEIN MP, IANNINI PB, STRAThospital entirely well 11 days after TON CW, et al: Spontaneous bacterial admission, taking phenoxymethyl peritonitis. A review of 28 cases with emphasis on improved survival and penicillin, 500 000 U orally every
factors influencing prognosis. Am J Med 64: 592, 1978 5. LIPSKY PE, HARDIN JA, SCHOUR L, et al: Spontaneous peritonitis and systemic lupus erythematosus. Importance of accurate diagnosis of gram-positive bacterial infections. JAMA 232: 929, 1975 6. CORREIA JP, CONN HO: Spontaneous bacterial peritonitis in cirrhosis endemic or epidemic? Med Clin
North Am 59: 963, 1975
BOOKS This list is an acknowledgement of books received. It does not preclude review at a later date. BIOCHEMISTRY. A Functional Approach. 2nd ed. R.W. McGilvery. 862 pp. lIlust. W.B. Saunders Company Canada Ltd., Toronto, 1979. $35.40. ISBN 0-7216-5912-8 COMPLIANCE IN HEALTH CARE. Edited by R. Brian Haynes, D. Wayne Taylor and David L. Sackett. 516 pp. IlIust. The Johns Hopkins University Press, Baltimore, 1979. $25. ISBN 0-8018-2162-2 DIAGNOSIS OF DISEASES OF THE CHEST. Volume IV. 2nd ed. Robert G. Fraser and J.A. Peter Pare. 280 pp. Illust. W.B. Saunders Company Canada Ltd., Toronto, 1979. $24. ISBN 0-72163855-4 THE HERITAGE OF AVIATION MED. ICINE. An Annotated Directory of Early Artifacts. Compiled by Robert J. Benford. 122 pp. Illust. Aerospace Medical Association, Washington, D.C., 1979. $4.50, paperbound. ISBN 0-93421600-2 MELLONI'S ILLUSTRATED MEDICAL DICTIONARY. Ida Dox, Biagio John Melloni and Gilbert M. Eisner. 530 pp. IlIust. The Williams & Wilkins Company, Baltimore; the Macmillan Company of Canada Limited, Toronto, 1979. $21.50. ISBN 0-683-02642-9 PSYCHIATRIC DIAGNOSIS. 2nd ed. Donald W. Goodwin and Samuel B. Guze. 254 pp. Oxford University Press, Inc., New York; Oxford University Press, Inc., Don Mills, Ont., 1979. $9.25, paperbound. ISBN 0-19-502513-X ULTRASTRUCTURAL ASPECTS OF THE LIVER AND ITS DISORDERS. 2nd ed. Kyuichi Tanikawa. 357 pp. IlIust. IgakuShoin Ltd., New York, 1979. $59. ISBN 0-89640-034-4 MINERAL/PROTEIN VITAMIN/TRACE INTERACTIONS. Volume 1. NW. Flodin. 217 pp. Eden Press Inc., Montreal, 1979. $22. ISBN 0-88831-042-0 WORLD REVIEW OF NUTRITION AND DIETETICS. Vol. 33. Some Special As* pects of Nutrition. Edited by Geoffrey H. Bourne. 233 pp. IlIust. S. Karger AG, Basel, 1979. $94.75. ISBN 3-8055-2942-2
CMA JOURNAL/AUGUST 18, 1979/VOL. 121 443
ogists in nonmetropolitan areas; in fact, their distribution closely resembled that of the internists described in our previous paper.3 Training more dermatologists would not necessarily correct the present maldistribution, as they might continue to set up practice in large cities and include primary care in their services. However, if dermatology were restricted to being a consulting specialty there would probably be an adequate supply of dermatologic services even with the present supply of practitioners, and the competitive forces of the marketplace might force some redistribution. This strategy would be especially timely in the present era of budgetary constraints, when it is considered wasteful to train specialists to provide primary care.10'1' Although this change would require considerable administrative effort and the passage of time, there is at present no financial incentive for medical specialists in Ontario to confine themselves to an entirely referral practice. The fee schedule is the most potent device for changing the pattern of practice. References 1. National Committee on Physician Manpower: Abstract, Commentary
2.
3.
4. 5.
6. 7.
8. 9.
10. 11.
and Recommendations of the Requirements Committee Based on the Report of the Workimig Party in Neurology, Dept of National Health and Welfare, Ottawa, 1975 National Committee on Physician Manpower: Abstract, Commentary and Recommendations of the Requirements Committee Based on the Report of the Working Party in Dermatology, Dept of National Health and Welfare, Ottawa, 1975 MCCONNON JK, SHAH CP: Patterns of practice of internal medicine in Ontario. Can Med Assoc J 116: 1269, 1977 Ontario Medical Directory - 1975, College of Physicians and Surgeons of Ontario, Toronto, 1975 LERNER HJ (ed): Manpower Issues and Voluntary Regulation in the Medical Specialty System, Prodist, New York, 1974, pp 28, 87 Medical staffing in the national health service in England and Wales. Lancet 1: 944, 1970 Population and Vital Statistics for England, 1974, Dept of Health and Social Security, HMSO, London, 1974, pp 11-57 SHAH CP: The Canadian pediatrician: a dilemma in child health. Can Med Assoc J 105: 1059, 1971 Cabinet committee on health, education and social policy: White Paper on Health Policy, Govt of Manitoba, Winnipeg, 1972, p 25 HOPKINs A: Consultants' work load (C). Lamicet 1: 956, 1976 LOUDON ISL: A question of numbers. Ibid, p 736
Spontaneous peritonitis due to group B streptococci ROBERT M. BANNATYNE, MB, CH B, DIP BACT, FRCP[C]; GUSTAVO STRINGEL, MD, FRCS[C]; JAMES S. SIMPSON, MD, FRCS[G], FAGS
Spontaneous bacterial peritonitis is a well recognized complication of nephrosis.1 Pneumococci feature prominently in the etiology.2 We describe a case in which the grampositive organisms seen in the smear of the peritoneal fluid were not pneumococci. From the departments of bacteriology and surgery, the Hospital for Sick Children, Toronto Reprint requests to: Dr. Robert M. Bannatyne, Department of bacteriology, The Hospital for Sick Children, 555 University Ave., Toronto, Ont. M5G 1X8
Case report A 12-year-old girl with nephrosis awoke suddenly from her sleep screaming. Severe pain was localized in the right lower quadrant of the abdomen, was worse with movement and was accompanied by mild diarrhea and vomiting. She had had four similar but less severe episodes, of unknown cause, in the past. Her temperature was 390C. At the time of admission to hospital 3 hours after the onset of the pain she was moaning and writhing. Abdominal guarding was impressive and she had rebound tender-
442 CMA JOURNAL/AUGUST 18, 1979/VOL. 121
ness, most marked on the right side and present also on rectal examination. Her bowel sounds were nor* mal. No evidence of perforation was obtained from roentgenography of the abdomen, nor were signs of an ulcer present on a roentgenogram made after a barium swallow. The leukocyte count was 22 >< 1O./l (92% neutrophils, 7% lymphocytes and 1 % band forms). A diagnosis of primary peritonitis was thought most likely. The girl was treated initially with meperidine hydrochloride, 50 mg intramuscularly for the pain, and nasogastric suction. A solution of
dextrose and saline in a 2:1 6 hours for a further week. In the ratio supplemented with potassium year since then she has remained chloride was infused intravenously. well. A search for group B streptococci Because she had been receiving tapering prednisone therapy an in- in the girl's throat, vagina and stool itial dose of hydrocortisone sodium while she was receiving antibiotic succinate (100 mg) was given intra- therapy was unsuccessful, so that a venously along with single doses of source of the organism could not methicillin (2 g), ampicillin (2 g) be identified. and gentamicin (42 mg) to combat Discussion the possible overwhelming sepsis. Bacterial peritonitis due to group A peritoneal tap was performed. The fluid was loaded with pus cells, B streptococci has previously been all neutrophils (10 x 10./l), and recorded in persons with cirrhosis gram-positive cocci, a considerable of the liver3'4 and systemic lupus proportion of which were distorted erythematosus.5 These conditions as a result of the antibiotic therapy. share with the nephrotic syndrome Countercurrent immunoelectrophor- certain features that may explain esis on the fluid was negative for their association with group B streppneumococci. Cultures of blood, tococcal peritonitis. In each condistool and urine collected prior to the tion the patient is immunologically initiation of antibiotic therapy were compromised, whether as a result negative at this point and remained of the disease or as a result of its treatment, and is therefore less able so. Intravenous administration of to resist bacteremic infections. This chloramphenicol, 100 mg/kg daily is especially so in those with cirdivided into 6-hourly doses, was rhosis, in whom the incidence of begun (the patient's weight was bacteremia may also be increased. 32 kg). Shock, attended by a fall in In the presence of portal hypertenblood pressure, an increase in heart sion the bacteria transiently present rate, a fall in central venous pres- in the portal blood may bypass the sure and coldness of the extremities liver (the primary filter for blooddue to poor perfusion, necessitated borne organisms) via the portalan infusion of crystalloid and col- systemic collateral blood vessels and bid. The patient's condition slowly give rise to prolonged 6 improved over the next 24 hours: The factor responsible for localizathe abdominal pain lessened tion of the infection in the penslightly, the temperature began to toneum in these three conditions is fall and she became more alert. undoubtedly the presence of ascitic Two days after admission to hos- fluid, which may not be clinically pital, culture of the peritoneal fluid detectable. Finally, the source of the yielded Lancefield group B strep- organisms most often associated tococci (grouping performed using with bacterial peritonitis is generally the Rantz-Randal antigen extrac- the gastrointestinal tract,4'6 and since tion method and the gel precipitin group B streptococci commonly reaction) sensitive to penicillin. The reside in this area the occurrence of chboramphenicol therapy (eight peritonitis due to this organism in doses, for a total of 25.6 g) was persons with the nephrotic synreplaced by intravenous adminis- drome should be predictable. tration of aqueous penicillin G, 12 MU/d divided into 6-hourly References doses. After two days the dose was 1. WILFERT CM, KATZ SL: Etiology of increased to 20 MU/d. Over the bacterial sepsis in nephrotic children 1963-1967. Pediatrics 42: 840, 1968 7 days of penicillin therapy marked clinical improvement was observed: 2. KUMAR R, MCGEOWN MG, McEvov J: Primary pneumococcal peritonitis the fever disappeared, the abdomen in the nephrotic syndrome. Postgrad became soft and nontender, the leuMed 1 48: 184, 1972 kocyte count reverted to normal and 3. GINSBERG MD: Spontaneous group B streptococcal bacteremia complicating the patient's condition returned to hepatic cirrhosis: report of two cases. what it had been before the onset of I Dig Dis 13: 1065, 1968 peritonitis. She was discharged from 4. Am WEINSTEIN MP, IANNINI PB, STRAThospital entirely well 11 days after TON CW, et al: Spontaneous bacterial admission, taking phenoxymethyl peritonitis. A review of 28 cases with emphasis on improved survival and penicillin, 500 000 U orally every
factors influencing prognosis. Am J Med 64: 592, 1978 5. LIPSKY PE, HARDIN JA, SCHOUR L, et al: Spontaneous peritonitis and systemic lupus erythematosus. Importance of accurate diagnosis of gram-positive bacterial infections. JAMA 232: 929, 1975 6. CORREIA JP, CONN HO: Spontaneous bacterial peritonitis in cirrhosis endemic or epidemic? Med Clin
North Am 59: 963, 1975
BOOKS This list is an acknowledgement of books received. It does not preclude review at a later date. BIOCHEMISTRY. A Functional Approach. 2nd ed. R.W. McGilvery. 862 pp. lIlust. W.B. Saunders Company Canada Ltd., Toronto, 1979. $35.40. ISBN 0-7216-5912-8 COMPLIANCE IN HEALTH CARE. Edited by R. Brian Haynes, D. Wayne Taylor and David L. Sackett. 516 pp. IlIust. The Johns Hopkins University Press, Baltimore, 1979. $25. ISBN 0-8018-2162-2 DIAGNOSIS OF DISEASES OF THE CHEST. Volume IV. 2nd ed. Robert G. Fraser and J.A. Peter Pare. 280 pp. Illust. W.B. Saunders Company Canada Ltd., Toronto, 1979. $24. ISBN 0-72163855-4 THE HERITAGE OF AVIATION MED. ICINE. An Annotated Directory of Early Artifacts. Compiled by Robert J. Benford. 122 pp. Illust. Aerospace Medical Association, Washington, D.C., 1979. $4.50, paperbound. ISBN 0-93421600-2 MELLONI'S ILLUSTRATED MEDICAL DICTIONARY. Ida Dox, Biagio John Melloni and Gilbert M. Eisner. 530 pp. IlIust. The Williams & Wilkins Company, Baltimore; the Macmillan Company of Canada Limited, Toronto, 1979. $21.50. ISBN 0-683-02642-9 PSYCHIATRIC DIAGNOSIS. 2nd ed. Donald W. Goodwin and Samuel B. Guze. 254 pp. Oxford University Press, Inc., New York; Oxford University Press, Inc., Don Mills, Ont., 1979. $9.25, paperbound. ISBN 0-19-502513-X ULTRASTRUCTURAL ASPECTS OF THE LIVER AND ITS DISORDERS. 2nd ed. Kyuichi Tanikawa. 357 pp. IlIust. IgakuShoin Ltd., New York, 1979. $59. ISBN 0-89640-034-4 MINERAL/PROTEIN VITAMIN/TRACE INTERACTIONS. Volume 1. NW. Flodin. 217 pp. Eden Press Inc., Montreal, 1979. $22. ISBN 0-88831-042-0 WORLD REVIEW OF NUTRITION AND DIETETICS. Vol. 33. Some Special As* pects of Nutrition. Edited by Geoffrey H. Bourne. 233 pp. IlIust. S. Karger AG, Basel, 1979. $94.75. ISBN 3-8055-2942-2
CMA JOURNAL/AUGUST 18, 1979/VOL. 121 443
