Effects of Squatting on the Normal and Failing Circulation

Two or more types of organisms may be present with different antibiotic susceptibilities. Thus, in one patient a faecal streptococcus was present, sensitive only to streptomycin; Proteus, sensitive only to chloramphenicol; and a staphylococcus which was insensitive to chloramphenicol. In these circumstances the use of a single selective antibiotic may make matters worse by removing one type of organism and so facilitating the growth of others. It may be better to reduce the whole mass of infection by the use of a quaternary ammonium compound such as cetrimide or domiphen bromide for cleaning the meatus. The alternative is to use a suitable combination of antibiotics. In infections due to one organism or organisms with similar antibiotic susceptibilities, various antibiotics, at one time or another, have their uses. The tetracyclines, chloramphenicol, neomycin, and polymyxin-B sulphate are most favoured, the last-named being effective against Ps. pyocyanea (Farrar, 1954). A French antibiotic, soframycin, now under trial, which is active against staphylococci, pseudomonas, proteus, and to a less extent against streptococci, seems to have a promising future. The use of sulphonamides, streptomycin, or penicillin is inadvisable because of the tendency of these substances to sensitize the skin. In order to prevent patients developing a sensitivity to valuable systemic antibiotics, it is inadvisable to use them for local application, and, where possible, antibiotics should be used which are not normally employed systemically. The risk is also avoided of the emergence of strains resistant to antibiotics used systemically. In this respect, neomycin and polymyxin-B are useful, and soframycin also seems most promising. A large mass of dry wax cannot be removed from the meatus with the oil treatment. From time to time various preparations containing benZine are advocated as efficient solvents of dry cerumen. They are good solvents, but they tend to enter the ducts of the secreting glands and may damage them. As the skin glands are probably at fault in any case, it is unwise to risk damaging them further. It is often the safest course to use the syringe to remove wax when the tympanic membrane is intact. It is advisable to instil oil into the meatus daily for several days before syringing. The patient lies with his meatus filled with oil for five minutes and then mops up the excess on rising. The patient is informed of the commoner sources of infection and is instructed in the need for adequate personal cleanliness. The nasal vestibule may also have to be treated if bacteriological investigations indicate that it is the probable source of contamination. The nasal vestibule is naturally contaminated by air-borne organisms and may also be contaminated from other parts of the body by the fingers. Any itchy, infected, or eroded skin lesions on other parts of the body should receive treatment at the same time. The hands and nails must be kept clean and the nails kept short. Investigation should be made to uncover any underlying anxiety state. Everything possible must be done to prevent scratching of the meatus and contamination by the fingers. In difficult cases 1% hydrocortisone ointment, applied twice daily, is often highly effective as an antipruritic application. It can also be applied in combination with the appropriate antibiotic, usually a tetracycline, neomycin, polymyxin-B, or soframycin. An evening dose of a barbiturate or of promethazine hydrochloride is often advisable while the itching persists.