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A MONOPOLY ?
956 He has made instructive list of overworked words that are often wrongly used and he gives their alternatives. One would like to see a copy of his readable and often humorous-guide on the desk of every official drafting the regulations for the National Health Service. Judging by the pensions regulations, the lessons of Plain Words have yet to be learnt in some departments.
(unnecessary abstract adjectival- phrase).
an
INFANTILE METHÆMOGLOBINÆMIA FROM DRINKING-WATER CYANOSIS is usually produced by reduced haemoglobin in the subpapillary venous plexuses of the skin,l but when it occurs without cardiac or pulmonary disease the presence of methæmoglobin or sulphaemoglobin in the blood must be considered. Since 1945 reports have been appearing in the North American p2ediatric and public-health journals of a cyanotic syndrome in infants due to methaemoglobinsemia. This condition is caused by the ingestion of water derived from rural wells and containing more than 10-20 parts per million of nitrate ions, a concentration which Comly2 looks upon as the maximum for waters which can safely be used for infant feeding. The nitrate ion is transformed by intestinal bacteria into nitrite and this is absorbed and converts some of the circulating haemoglobin into methaemoglobin. The nitrates which find their wayinto the well water are formed by the action of soil bacteria on nitrogen compounds present in fertile humus. The wells are usually rather shallow and inefficiently lined. Waters containing large amounts of nitrate are reported by Weart 3 from various areas of the United States, Canada, England, and Belgium, and Weart has found no correlation between the nitrate content of well waters and their contamination with coliform bacteria. That nitrates can be responsible for methaemoglobinsemia has been known since the introduction of bismuth subnitrate in radiology. Death has been reported4 after the administration of bismuth subnitrate for the treatment of diarrhoea in a young infant. The nitrates share their property of the intracorpuscular production of methæmoglobin with coal-tar derivatives, such as are used in the manufacture of aniline dyes and explosives, and with various drugs such as acetanilide, antipyrin, phenacetin, potassium chlorate, and sulphonamides. Extracorpuscular methæmoglobinæmia is found in phenylhydrazine poisoning and in severe infections (01. welchii). Some of these drugs may cause sulphaemoglobin2emia if an excess of sulphide is present in the gastro-intestinal tract. In " enterogenous cyanosis the abnormal pigment is found in the red blood-cells even if no drug has been taken.5 It is suggested that this condition is due to excessive nitrate production in the gastroThere are a few cases on record of intestinal tract. familial methæmoglobinæmia with cyanosis, idiopathic possibly due to a congenital metabolic error 6; these cases respond to large doses of ascorbic acid by mouth. Nitrate methæmoglobinæmia is much more common in infants than in adults. Of the various possible reasons for this, the relatively large intake of water in infancy is probably the most important ; others are the presence of smaller amounts of oxidisable haemoglobin in the infant’s blood ; the more ready absorption of nitrites in the infant’s gut and possibly a larger formation of nitrites due to differences in bacterial flora ; and poor elimination by the immature infantile kidney. Ascorbic acid in the blood may counteract the action of nitrites on haemoglobin, and depletion of ascorbic acid may "
‘
1.
2. 3.
4. 5. 6. 7.
Lancet, 1947, ii, 431. Comly, H. H. J. Amer. med. Ass., 1945, 129, 112. Weart, J. G. Paper presented at the American Chemical Society meeting of April 19, 1948. Roe, H. E. J. Amer. med. Ass. 1933, 101, 352. Stokvis, B. J. Ned. Tijdschr. Geneesk. 1902, 2, 678. Denny J., Murdoch, E. T., Rogan, J. J. Brit. med. J. 1943, i, 721. Carnrick, M., Polis, B. D., Klein, T. Arch. intern. Med. 1946, 78, 296.
account for the rapid development of cyanosis after an infant has been taking a high nitrate water for some time. The clinical picture is one of cyanosis and occasional drowsiness, often with gastro-intestinal disturbances ; the condition may be fatal in consequence of anoxæmia. In the State of Illinois Weart has learnt of 33 cases of nitrate cyanosis in the last year, with 5 deaths. The symptoms are said to be quickly relieved by the intravenous administration of methylene-blue (1-2 mg. per kg. body-weight) and exclusion from the diet of the offending water, so presumably the condition is only dangerous if it is unsuspected. -
THE BIRTHDAY HONOURS THE first name in the list of honours gazetted last week is that of Sir Alfred Webb-Johnson, who is created a baron. His many friends will be happy that his work is thus recognised, and the profession as a whole will be glad to have another able representative in the House of Lords. It cannot have escaped notice that Sir Alfred is a specialist in restoring vigour to ancient institutions : he is largely responsible for the new Middlesex Hospital, and under his presidency in the difficult years since 1941 the Royal College of Surgeons has become once more a great and developing centre of teaching, full of activity and hope. The president of a sister college is also honoured, and much pleasure will be given to his colleagues by the knighthood now bestowed on Mr. William Gilliatt, obstetric and gynaecological surgeon to King’s College Hospital. Air Vice-Marshal A. F. Rook is promoted K.B.E. for his distinguished service as consultant in medicine to the Royal Air Force, and the new knights also include Mr. J. N. Morris, F.R.A.C.S., Dr. D. T. Rocyn-Jones, formerly medical officer of health for Monmouthshire, and, outside the nominal confines of the medical profession, Mr. Charles Harington, D.SC., F.R.s., director of the National Institute of Medical Research. To these and many others mentioned on another page we offer warm congratulations. A MONOPOLY ? IN a letter this week Mr. E. R. Desoutter, on behalf of the Surgical Instrument Manufacturers’ Association, calls attention to the decision that in the National Health Service artificial limbs will be supplied only through the Ministry of Pensions, which will obtain them all from two contractors. This means, he says, that most of the private firms making artificial limbs are threatened with extinction ; and it has already been announced that his own firm, Desoutter Bros. Ltd., has been obliged to discontinue this work. In Tuesday’s Times, Prof. H. J. Seddon, F.R.c.s., recalls the departmental committee’s recommendation that ".no action shall be taken by the Government which would have the effect of gradually forcing out of business those firms which do not supply the Government." He appears to be right in saying that " unless the present plan is changed an almost complete and a very unhealthy monopoly will be created."
SPENS REPORT AND REPRESENTATION OF SPECIALISTS A MEETING held on June 14 at the Royal College of Physicians was attended by 59 consultants and specialists, including representatives of the three Royal Colleges, the Scottish Medical Corporations, all the specialties, and the Provincial Teaching Hospitals Association. The following resolutions were passed
unanimously : (i) (ii)
This meeting approves in principle the Spens report, recommends its adoption, and hopes the Government will implement it. This committee should continue in existence in order to consider matters which concern consultants and
specialists.
(unnecessary abstract adjectival- phrase).
an
INFANTILE METHÆMOGLOBINÆMIA FROM DRINKING-WATER CYANOSIS is usually produced by reduced haemoglobin in the subpapillary venous plexuses of the skin,l but when it occurs without cardiac or pulmonary disease the presence of methæmoglobin or sulphaemoglobin in the blood must be considered. Since 1945 reports have been appearing in the North American p2ediatric and public-health journals of a cyanotic syndrome in infants due to methaemoglobinsemia. This condition is caused by the ingestion of water derived from rural wells and containing more than 10-20 parts per million of nitrate ions, a concentration which Comly2 looks upon as the maximum for waters which can safely be used for infant feeding. The nitrate ion is transformed by intestinal bacteria into nitrite and this is absorbed and converts some of the circulating haemoglobin into methaemoglobin. The nitrates which find their wayinto the well water are formed by the action of soil bacteria on nitrogen compounds present in fertile humus. The wells are usually rather shallow and inefficiently lined. Waters containing large amounts of nitrate are reported by Weart 3 from various areas of the United States, Canada, England, and Belgium, and Weart has found no correlation between the nitrate content of well waters and their contamination with coliform bacteria. That nitrates can be responsible for methaemoglobinsemia has been known since the introduction of bismuth subnitrate in radiology. Death has been reported4 after the administration of bismuth subnitrate for the treatment of diarrhoea in a young infant. The nitrates share their property of the intracorpuscular production of methæmoglobin with coal-tar derivatives, such as are used in the manufacture of aniline dyes and explosives, and with various drugs such as acetanilide, antipyrin, phenacetin, potassium chlorate, and sulphonamides. Extracorpuscular methæmoglobinæmia is found in phenylhydrazine poisoning and in severe infections (01. welchii). Some of these drugs may cause sulphaemoglobin2emia if an excess of sulphide is present in the gastro-intestinal tract. In " enterogenous cyanosis the abnormal pigment is found in the red blood-cells even if no drug has been taken.5 It is suggested that this condition is due to excessive nitrate production in the gastroThere are a few cases on record of intestinal tract. familial methæmoglobinæmia with cyanosis, idiopathic possibly due to a congenital metabolic error 6; these cases respond to large doses of ascorbic acid by mouth. Nitrate methæmoglobinæmia is much more common in infants than in adults. Of the various possible reasons for this, the relatively large intake of water in infancy is probably the most important ; others are the presence of smaller amounts of oxidisable haemoglobin in the infant’s blood ; the more ready absorption of nitrites in the infant’s gut and possibly a larger formation of nitrites due to differences in bacterial flora ; and poor elimination by the immature infantile kidney. Ascorbic acid in the blood may counteract the action of nitrites on haemoglobin, and depletion of ascorbic acid may "
‘
1.
2. 3.
4. 5. 6. 7.
Lancet, 1947, ii, 431. Comly, H. H. J. Amer. med. Ass., 1945, 129, 112. Weart, J. G. Paper presented at the American Chemical Society meeting of April 19, 1948. Roe, H. E. J. Amer. med. Ass. 1933, 101, 352. Stokvis, B. J. Ned. Tijdschr. Geneesk. 1902, 2, 678. Denny J., Murdoch, E. T., Rogan, J. J. Brit. med. J. 1943, i, 721. Carnrick, M., Polis, B. D., Klein, T. Arch. intern. Med. 1946, 78, 296.
account for the rapid development of cyanosis after an infant has been taking a high nitrate water for some time. The clinical picture is one of cyanosis and occasional drowsiness, often with gastro-intestinal disturbances ; the condition may be fatal in consequence of anoxæmia. In the State of Illinois Weart has learnt of 33 cases of nitrate cyanosis in the last year, with 5 deaths. The symptoms are said to be quickly relieved by the intravenous administration of methylene-blue (1-2 mg. per kg. body-weight) and exclusion from the diet of the offending water, so presumably the condition is only dangerous if it is unsuspected. -
THE BIRTHDAY HONOURS THE first name in the list of honours gazetted last week is that of Sir Alfred Webb-Johnson, who is created a baron. His many friends will be happy that his work is thus recognised, and the profession as a whole will be glad to have another able representative in the House of Lords. It cannot have escaped notice that Sir Alfred is a specialist in restoring vigour to ancient institutions : he is largely responsible for the new Middlesex Hospital, and under his presidency in the difficult years since 1941 the Royal College of Surgeons has become once more a great and developing centre of teaching, full of activity and hope. The president of a sister college is also honoured, and much pleasure will be given to his colleagues by the knighthood now bestowed on Mr. William Gilliatt, obstetric and gynaecological surgeon to King’s College Hospital. Air Vice-Marshal A. F. Rook is promoted K.B.E. for his distinguished service as consultant in medicine to the Royal Air Force, and the new knights also include Mr. J. N. Morris, F.R.A.C.S., Dr. D. T. Rocyn-Jones, formerly medical officer of health for Monmouthshire, and, outside the nominal confines of the medical profession, Mr. Charles Harington, D.SC., F.R.s., director of the National Institute of Medical Research. To these and many others mentioned on another page we offer warm congratulations. A MONOPOLY ? IN a letter this week Mr. E. R. Desoutter, on behalf of the Surgical Instrument Manufacturers’ Association, calls attention to the decision that in the National Health Service artificial limbs will be supplied only through the Ministry of Pensions, which will obtain them all from two contractors. This means, he says, that most of the private firms making artificial limbs are threatened with extinction ; and it has already been announced that his own firm, Desoutter Bros. Ltd., has been obliged to discontinue this work. In Tuesday’s Times, Prof. H. J. Seddon, F.R.c.s., recalls the departmental committee’s recommendation that ".no action shall be taken by the Government which would have the effect of gradually forcing out of business those firms which do not supply the Government." He appears to be right in saying that " unless the present plan is changed an almost complete and a very unhealthy monopoly will be created."
SPENS REPORT AND REPRESENTATION OF SPECIALISTS A MEETING held on June 14 at the Royal College of Physicians was attended by 59 consultants and specialists, including representatives of the three Royal Colleges, the Scottish Medical Corporations, all the specialties, and the Provincial Teaching Hospitals Association. The following resolutions were passed
unanimously : (i) (ii)
This meeting approves in principle the Spens report, recommends its adoption, and hopes the Government will implement it. This committee should continue in existence in order to consider matters which concern consultants and
specialists.