- Email: [email protected]
AMENORRHŒA AFTER ORAL CONTRACEPTIVES
643 behaviour to be repeated, and for these studies to be carried out in different situations, so that both genetic and environmental factors concerning platelet function may be examined. The evidence that increased platelet adhesiveness plays a major role in the initiation of venous thrombosis is not overwhelming, and evidence for its role in ischaemic heartdisease remains doubtful.
THE SUPER-CONSULTANT SYSTEM
platelet
Cardiovascular Research Unit,
Department of Medicine, Makerere University College Medical School,
Kampala, Uganda.
A. G. SHAPER.
OSTEOPOROSIS: DISEASE OR SENESCENCE ? SIR,-Dr. Saville (March 9, p. 535), perhaps unwittingly, has produced further evidence to support our hypothesis that all persons lose bone with age and that it is the ones with thin bones at each age who are at risk for fracture. His figure, which is misleading in that it shows mean -4-S.E.M. for controls and mean :s.D. for osteoporotics, clearly demonstrates both these facts. University Clinical Investigation Unit, H. F. NEWTON-JOHN The General Infirmary, D. B. MORGAN. Leeds 1.
SEVERE HEAD INJURIES SIR,-Your leading article (March 9, p. 514) gives due credit to the application of " intensive care " as we now call it for the reduction in mortality which Maciver and his colleagues reported, but makes no reference to the contribution that chlorpromazine might have made to both their shortterm and long-term results. Maciverwas very insistent that chlorpromazine reduced the severity of shock and reduced long-term morbidity after head injuries. Part of the grounds for this belief was a report by Pocidalo and Tardieu2 that pretreatment with chlorpromazine increased survival-time and diminished the severity of lesions produced in dogs by injecting irritant solutions into the cerebral peduncles. One of these dogs survived several weeks before being killed to confirm that the solution had been correctly placed. In previous attempts with other drugs, no dog had lived for more than 24 hours. Since that time, work by Bradley3 on cats has shown that chlorpromazine has a selective depressant action on sensory inflow to the brainstem reticular system from the classical afferent sensory pathways. The significance of these findings must to some extent remain speculative until more precise information is available about the neurophysiology of this part of the brain. Nevertheless, clinical experience with chlorpromazine suggests that such an action could explain the protection by chlorpromazine against stressful situations, and the modification of the vasoconstrictor and vasospastic effects which follow. Connections of the brainstem with the hypothalamus and the sympathetic outflow offer grounds for such an assumption. Maciver’s prediction that the morbidity of patients treated with chlorpromazine would be reduced seems to be supported by Miller and Stern 4 and it is a misfortune that Maciver’s early death prevented his development of a line of treatment which he thought so full of promise. It may seem an impertinence for an anxsthetist to make suggestions on a subject outside his own specialty, but, since the early suggestions on the value of chlorpromazine in shock prevention and treatment are now receiving confirmation,5 a fresh look at its usefulness in treatment of severe head injuries might be justified. Department of Anaesthesia, Charing Cross Hospital, D. A. BUXTON HOPKIN. London W.C.2. 1. 2. 3.
Maciver, I. N. Personal communication. Pocidalo, J. J., Tardieu, C. C. r. Séanc. Soc. Biol. 1954, 148, 452. Bradley, P. B. in Psychotropic Drugs (edited by S. Garattini and V. Ghetti); p. 207. Amsterdam, 1957. 4. Miller, H., Stern, G. Lancet, 1965, i, 225. 5. Collins, V. J., Jaffee, R., Zahony, I. Illinois med. J. 1962, 127, 35.
SIR,-In the letter by Mr. MacDonald (March 2,
p. 470) subsequent letters on the same subject it is generally accepted that the position of non-administrative consultants in England is much better than in Scotland. This is almost certainly true in those specialties in which a consultant is in a position to have his own beds and his own outpatient clinics, but it is certainly not true in two important specialtiesnamely, radiology and pathology-in which the organisation is related not to a consultant’s personal list of patients but to the total work-load organised by the consultant in administrative charge. The non-administrative consultants in these departments are entirely dependent on the good will of their administrative colleague. In those places where the system
and in
works it works very well, but it is also true that the administrator has absolute power. Those who deal with departments of radiology and pathology as a rule do not deal with individual consultants but with the department, and the department is the consultant in administrative charge. The Ministry of Health states that all consultants should have equal professional status. If this is to be made fact instead of fancy a new system of administrating departments is urgently required, such as by appointing a different administrator every five years. In a well-run department with full consultation this could do no harm and certainly, in other departments, a lot of good. Department of Pathology, General Hospital, West Hartlepool, Co. Durham.
H. MCTAGGART.
AMENORRHŒA AFTER ORAL CONTRACEPTIVES
SiR,—Ihave read Dr. Shearman’s article (Feb. 17, p. 325) with interest. As a medical officer with 17 years’ experience of contraceptive methods and 4 years’ clinical experience of oral contraception, I should like to comment. At a local-authority family planning clinic in Aberdeen, approximately 70% of patients are constantly on oral contraception and there are approximately 5000 patients attending
annually. I note that 8 out of 22 cases described by Dr. Shearman had natural amenorrhoeic cycles ranging from two to eight months before beginning oral contraception; yet all but two of the oral contraceptives listed contained very large doses of synthetic testosterone, which could be expected only to increase this obvious tendency to amenorrhoea in these 8 patients. In the others with a presumably normal cycle (though the amount of their menstrual loss, which gives important information, is not disclosed), long-continued use of such testosterones might have led to amenorrhoea, but this could doubtless have been corrected by a timely change to a synthetic progesterone. In this clinic we attempt to make a rough clinical assessment of the patient’s type of ovarian cycle before prescribing a product. A patient with a history of previous habitual amenorrhoeic cycles would not be given a product containing a high dosage of testosterone. The latter, of course, has its place in oral contraception when chosen for suitable patients. All our patients are examined every six months, many of them much more frequently. We have never encountered hirsutism, galactorrhoea, jaundice, or iatrogenic amenorrhcea in any of our patients. The occasional amenorrhceic cycle has been observed, and, if this pattern recurs, the oral contraceptive is changed, either to a much-lower-dosage testosterone or to a synthetic progesterone. I have seen only two patients with iatrogenic amenorrhoea, each of whom had been on a highdosage synthetic testosterone for four years before attending the clinic. It has been shown that the effect of oral contraception is completely reversible and that the hypoplastic endometrium returns to normal within three cycles after stopping the pill.! I do not doubt that Dr. Shearman’s cases are genuinely 1.
Flowers, C. E.,
et
al.
Am.
J. Obstet. Gynec. 1966, 96, 784.
644 was not this avoidable ? In my opinion he has described a series of artefacts caused by an unfortunate choice of oral contraceptives in the first place for those individual oatients.
iatrogenic, but
Authority Family Planning Clinic,
Local
Aberdeen AB2 1AA.
MARGARET S. M. MCGREGOR.
THE NICOTINE HABIT with read interest your annotation last week (p. 579). SIR,-I Kershbaum et al.1 have reported a rise in plasma 11-hydroxycorticosteroids (11-OHc.s.) after heavy cigarette smoking in human subjects. I should like to suggest that this finding may play a part in the development of the nicotine habit. Heavy smoking under stress is well known and it may be that certain individuals have a slow or inadequate response to corticosteroid production to stress. Smoking may stimulate the required increased output of 11-OHc.s. It would be of interest to investigate adrenal function in groups of smokers and nonsmokers, especially noting any delay in response of plasma 11-OHc.s. after corticotrophin stimulation. Charing Cross Hospital Medical School B. J. B. GRANT. London W.C.2.
AUTOANTIBODIES AND METHYLDOPA SIR,-Dr. Breckenridge and his colleagues,2 in their study of the relation between a-methyldopa (methyldopa,Aldomet ’) and a positive anti-human-globulin (A.H.G.) test on red cells, found antinuclear factor (A.N.F.) in 15% of sera from hypertensive patients treated with methyldopa, and in 4% of such patients on other drugs. We have examined sera from 145 hypertensive patients and an equal number of normal subjects, matched for sex and age, by the indirect immunofluorescent technique, for antibodies against thyroid, gastric mucosa, adrenal cortex, skeletal muscle, thymic myoid cells, parotid salivary ducts, smooth muscle, and mitochondria.3 Antibodies only to gastric parietal cells were found in diluted sera (1/20) in 18 (12%) of the 145 hypertensive patients and in 7 (5%) of the 145 normal subjects (P<0-05). However, these antibodies were not more common in methyldopa-treated patients (11%) than in hypertensive patients not on this drug (16%). The technique for detecting the above antibodies also revealed A.N.F. if present. Human thyroid, adrenal, and parotid glands, rat diaphragm, kidney, and gastric mucosa, and fowl thymus were used as nuclear substrates. With one or more of these substrates A.N.F. was found in diluted sera (1/10) in 22% of the 145 hypertensive patients and in 1% of the matched controls. A.N.F. was demonstrated in this way in 28% of methyldopa-treated hypertensive patients and in only 16% of hypertensive patients not treated with this drug; although this difference is not significant, the A.N.F. was found significantly more frequently in the methyldopa-treated patients (20%) than in the patients not on this drug (4%), when adrenal cortex was used as substrate. 7 (5%) out of the 145 hypertensive patients had a positive direct A.H.G. test. A.N.F. was found with one or more substrates, in the serum of 4 (57%) of these 7 patients, but in only 28 (20%) of 138 hypertensive patients with a negative direct A.H.G. test (p < 0-05). Patients treated with methyldopa showed a similar, but not statistically significant, difference (p < 0’1). None of the A.N.F.-positive sera gave a positive L.E.-cell test. The rheumatoid factor, determined with human 0-group red cells,3 was present in 5 (3%) of 145 sera from hypertensive patients and in none of the controls, but its presence was not related to methyldopa treatment.
treatment
1. 2. 3.
Kershbaum, A., Pappajohn, D. J., Bellet, S., Hirabayashi, M., Shafiha, H. J. Am. med. Ass. 1968, 203, 275. Breckenridge, A., Dollery, C. T., Worlledge, S. M., Holborow, E. J., Johnson, G. D. Lancet, 1967, ii, 1265. Feltkamp, T. E. W., van Rossum, A. L. Clin. exp. Immun. 1968, 3, 1. van Loghem-Langereis, P. E. Bull. cent. Lab. BloedtransfDienst ned Rode Kruis, 1952, 2, 230.
These findings, which confirm and extend those of Dr. Breckenridge and his colleagues, will be reported in detail, together with a study on possible relations between serological abnormalities, duration and dosage of methyldopa treatment, and the cause of hyper-
tension. We acknowledge the cooperation of the colleagues who sent us blood-samples and clinical data from their patients, and the financial support of Merck Sharp and Dohme Nederland N.V. Central Laboratory of the Netherlands Red Cross Blood Transfusion Service, Amsterdam.
T. E. W. FELTKAMP C. P. ENGELFRIET J. J. VAN LOGHEM.
HYPOCALCÆMIC FITS IN NEONATES SiR,ňThe concern of Dr. Baum and his colleagues (last week, p. 598) with the increased prevalence of hypocalcasmic fits in newborn infants is not peculiar to Hammersmith Hospital. In a local maternity unit, feeding infants on one part evaporated milk with two parts water, given ad lib from the first minutes of life, tetany by the end of the first week is becoming commonplace. This involves mature infants, regardless of sex, begins with irritability and rhythmical trembling, and may proceed to prolonged generalised convulsions. Substitution of’S.M.A.’ feeds restores health after a few days, but not without anxiety in individual cases, and administrative problems. It may be relevant that in another maternity unit, dealing with three times as many babies but feeding reconstituted dried cow’s milk with equal liberality, neonatal tetany remains exceptional. It does not seem likely that early exposure to a high phosphate load can be the whole explanation, and re-examination of the prevailing approach to feeding may well be desirable as your correspondents suggest. The Hull
Royal Infirmary, Hull, Yorkshire.
R.
J. PUGH.
SIR,-Iwas interested to read the letter by Dr. Baum and his colleagues. My own experience confirms their observation that there has been an increase in this condition in the past two to three years. Working in three different units during this period I can recall seeing a total of 7 cases since 1965, whereas in the preceding seven years, while working in much larger obstetric units, I can remember only about 4. Comparing notes with 2 pwdiatric registrars from other units a year or so ago, I remember that their impression was much the same. I had concluded that the increase was related to the decline in breast-feeding in the first week of life, and have said as much to midwives and medical students. It used to be the practice in most maternity units to assume that mothers would breast-feed (and indeed in some to insist on this), leaving those who felt inclined to change to dried milk after they went home. Infants appear to be vulnerable to the high phosphate content of cow’s milk only in the first two weeks or so of life: this may have prevented as many cases of neonatal tetany as we see now. The present practice in many units seems to be to ask the mother whether she wishes to breast-feed, and if the answer is in the negative to suppress lactation. This brings me to the second conclusion of your correspondents-namely, that too large a volume of cow’s milk is used in the first week of life. Here again I am in agreement with them. I have been surprised to find bottle-fed babies offered the full calculated 21/2 oz. per 50 calories per lb. on the second and third day of life. I was brought up on the " rule of sevens "-i.e., allowing 1/7 of the calculated requirements on the first day, 2/,th on the second, and so on, reaching the full amount at one week. Perhaps the recent emphasis on the high calorie requirements of the " small for dates " and low-birth-weight infants has led to confusion in the minds of midwives on the question of infant feeding generally. It is to be hoped that these latest observations from the Hammersmith unit will cause paediatricians to take a closer look at the feeding regimens in their maternity units. Incidentally, I should be interested to hear whether anyone
THE SUPER-CONSULTANT SYSTEM
platelet
Cardiovascular Research Unit,
Department of Medicine, Makerere University College Medical School,
Kampala, Uganda.
A. G. SHAPER.
OSTEOPOROSIS: DISEASE OR SENESCENCE ? SIR,-Dr. Saville (March 9, p. 535), perhaps unwittingly, has produced further evidence to support our hypothesis that all persons lose bone with age and that it is the ones with thin bones at each age who are at risk for fracture. His figure, which is misleading in that it shows mean -4-S.E.M. for controls and mean :s.D. for osteoporotics, clearly demonstrates both these facts. University Clinical Investigation Unit, H. F. NEWTON-JOHN The General Infirmary, D. B. MORGAN. Leeds 1.
SEVERE HEAD INJURIES SIR,-Your leading article (March 9, p. 514) gives due credit to the application of " intensive care " as we now call it for the reduction in mortality which Maciver and his colleagues reported, but makes no reference to the contribution that chlorpromazine might have made to both their shortterm and long-term results. Maciverwas very insistent that chlorpromazine reduced the severity of shock and reduced long-term morbidity after head injuries. Part of the grounds for this belief was a report by Pocidalo and Tardieu2 that pretreatment with chlorpromazine increased survival-time and diminished the severity of lesions produced in dogs by injecting irritant solutions into the cerebral peduncles. One of these dogs survived several weeks before being killed to confirm that the solution had been correctly placed. In previous attempts with other drugs, no dog had lived for more than 24 hours. Since that time, work by Bradley3 on cats has shown that chlorpromazine has a selective depressant action on sensory inflow to the brainstem reticular system from the classical afferent sensory pathways. The significance of these findings must to some extent remain speculative until more precise information is available about the neurophysiology of this part of the brain. Nevertheless, clinical experience with chlorpromazine suggests that such an action could explain the protection by chlorpromazine against stressful situations, and the modification of the vasoconstrictor and vasospastic effects which follow. Connections of the brainstem with the hypothalamus and the sympathetic outflow offer grounds for such an assumption. Maciver’s prediction that the morbidity of patients treated with chlorpromazine would be reduced seems to be supported by Miller and Stern 4 and it is a misfortune that Maciver’s early death prevented his development of a line of treatment which he thought so full of promise. It may seem an impertinence for an anxsthetist to make suggestions on a subject outside his own specialty, but, since the early suggestions on the value of chlorpromazine in shock prevention and treatment are now receiving confirmation,5 a fresh look at its usefulness in treatment of severe head injuries might be justified. Department of Anaesthesia, Charing Cross Hospital, D. A. BUXTON HOPKIN. London W.C.2. 1. 2. 3.
Maciver, I. N. Personal communication. Pocidalo, J. J., Tardieu, C. C. r. Séanc. Soc. Biol. 1954, 148, 452. Bradley, P. B. in Psychotropic Drugs (edited by S. Garattini and V. Ghetti); p. 207. Amsterdam, 1957. 4. Miller, H., Stern, G. Lancet, 1965, i, 225. 5. Collins, V. J., Jaffee, R., Zahony, I. Illinois med. J. 1962, 127, 35.
SIR,-In the letter by Mr. MacDonald (March 2,
p. 470) subsequent letters on the same subject it is generally accepted that the position of non-administrative consultants in England is much better than in Scotland. This is almost certainly true in those specialties in which a consultant is in a position to have his own beds and his own outpatient clinics, but it is certainly not true in two important specialtiesnamely, radiology and pathology-in which the organisation is related not to a consultant’s personal list of patients but to the total work-load organised by the consultant in administrative charge. The non-administrative consultants in these departments are entirely dependent on the good will of their administrative colleague. In those places where the system
and in
works it works very well, but it is also true that the administrator has absolute power. Those who deal with departments of radiology and pathology as a rule do not deal with individual consultants but with the department, and the department is the consultant in administrative charge. The Ministry of Health states that all consultants should have equal professional status. If this is to be made fact instead of fancy a new system of administrating departments is urgently required, such as by appointing a different administrator every five years. In a well-run department with full consultation this could do no harm and certainly, in other departments, a lot of good. Department of Pathology, General Hospital, West Hartlepool, Co. Durham.
H. MCTAGGART.
AMENORRHŒA AFTER ORAL CONTRACEPTIVES
SiR,—Ihave read Dr. Shearman’s article (Feb. 17, p. 325) with interest. As a medical officer with 17 years’ experience of contraceptive methods and 4 years’ clinical experience of oral contraception, I should like to comment. At a local-authority family planning clinic in Aberdeen, approximately 70% of patients are constantly on oral contraception and there are approximately 5000 patients attending
annually. I note that 8 out of 22 cases described by Dr. Shearman had natural amenorrhoeic cycles ranging from two to eight months before beginning oral contraception; yet all but two of the oral contraceptives listed contained very large doses of synthetic testosterone, which could be expected only to increase this obvious tendency to amenorrhoea in these 8 patients. In the others with a presumably normal cycle (though the amount of their menstrual loss, which gives important information, is not disclosed), long-continued use of such testosterones might have led to amenorrhoea, but this could doubtless have been corrected by a timely change to a synthetic progesterone. In this clinic we attempt to make a rough clinical assessment of the patient’s type of ovarian cycle before prescribing a product. A patient with a history of previous habitual amenorrhoeic cycles would not be given a product containing a high dosage of testosterone. The latter, of course, has its place in oral contraception when chosen for suitable patients. All our patients are examined every six months, many of them much more frequently. We have never encountered hirsutism, galactorrhoea, jaundice, or iatrogenic amenorrhcea in any of our patients. The occasional amenorrhceic cycle has been observed, and, if this pattern recurs, the oral contraceptive is changed, either to a much-lower-dosage testosterone or to a synthetic progesterone. I have seen only two patients with iatrogenic amenorrhoea, each of whom had been on a highdosage synthetic testosterone for four years before attending the clinic. It has been shown that the effect of oral contraception is completely reversible and that the hypoplastic endometrium returns to normal within three cycles after stopping the pill.! I do not doubt that Dr. Shearman’s cases are genuinely 1.
Flowers, C. E.,
et
al.
Am.
J. Obstet. Gynec. 1966, 96, 784.
644 was not this avoidable ? In my opinion he has described a series of artefacts caused by an unfortunate choice of oral contraceptives in the first place for those individual oatients.
iatrogenic, but
Authority Family Planning Clinic,
Local
Aberdeen AB2 1AA.
MARGARET S. M. MCGREGOR.
THE NICOTINE HABIT with read interest your annotation last week (p. 579). SIR,-I Kershbaum et al.1 have reported a rise in plasma 11-hydroxycorticosteroids (11-OHc.s.) after heavy cigarette smoking in human subjects. I should like to suggest that this finding may play a part in the development of the nicotine habit. Heavy smoking under stress is well known and it may be that certain individuals have a slow or inadequate response to corticosteroid production to stress. Smoking may stimulate the required increased output of 11-OHc.s. It would be of interest to investigate adrenal function in groups of smokers and nonsmokers, especially noting any delay in response of plasma 11-OHc.s. after corticotrophin stimulation. Charing Cross Hospital Medical School B. J. B. GRANT. London W.C.2.
AUTOANTIBODIES AND METHYLDOPA SIR,-Dr. Breckenridge and his colleagues,2 in their study of the relation between a-methyldopa (methyldopa,Aldomet ’) and a positive anti-human-globulin (A.H.G.) test on red cells, found antinuclear factor (A.N.F.) in 15% of sera from hypertensive patients treated with methyldopa, and in 4% of such patients on other drugs. We have examined sera from 145 hypertensive patients and an equal number of normal subjects, matched for sex and age, by the indirect immunofluorescent technique, for antibodies against thyroid, gastric mucosa, adrenal cortex, skeletal muscle, thymic myoid cells, parotid salivary ducts, smooth muscle, and mitochondria.3 Antibodies only to gastric parietal cells were found in diluted sera (1/20) in 18 (12%) of the 145 hypertensive patients and in 7 (5%) of the 145 normal subjects (P<0-05). However, these antibodies were not more common in methyldopa-treated patients (11%) than in hypertensive patients not on this drug (16%). The technique for detecting the above antibodies also revealed A.N.F. if present. Human thyroid, adrenal, and parotid glands, rat diaphragm, kidney, and gastric mucosa, and fowl thymus were used as nuclear substrates. With one or more of these substrates A.N.F. was found in diluted sera (1/10) in 22% of the 145 hypertensive patients and in 1% of the matched controls. A.N.F. was demonstrated in this way in 28% of methyldopa-treated hypertensive patients and in only 16% of hypertensive patients not treated with this drug; although this difference is not significant, the A.N.F. was found significantly more frequently in the methyldopa-treated patients (20%) than in the patients not on this drug (4%), when adrenal cortex was used as substrate. 7 (5%) out of the 145 hypertensive patients had a positive direct A.H.G. test. A.N.F. was found with one or more substrates, in the serum of 4 (57%) of these 7 patients, but in only 28 (20%) of 138 hypertensive patients with a negative direct A.H.G. test (p < 0-05). Patients treated with methyldopa showed a similar, but not statistically significant, difference (p < 0’1). None of the A.N.F.-positive sera gave a positive L.E.-cell test. The rheumatoid factor, determined with human 0-group red cells,3 was present in 5 (3%) of 145 sera from hypertensive patients and in none of the controls, but its presence was not related to methyldopa treatment.
treatment
1. 2. 3.
Kershbaum, A., Pappajohn, D. J., Bellet, S., Hirabayashi, M., Shafiha, H. J. Am. med. Ass. 1968, 203, 275. Breckenridge, A., Dollery, C. T., Worlledge, S. M., Holborow, E. J., Johnson, G. D. Lancet, 1967, ii, 1265. Feltkamp, T. E. W., van Rossum, A. L. Clin. exp. Immun. 1968, 3, 1. van Loghem-Langereis, P. E. Bull. cent. Lab. BloedtransfDienst ned Rode Kruis, 1952, 2, 230.
These findings, which confirm and extend those of Dr. Breckenridge and his colleagues, will be reported in detail, together with a study on possible relations between serological abnormalities, duration and dosage of methyldopa treatment, and the cause of hyper-
tension. We acknowledge the cooperation of the colleagues who sent us blood-samples and clinical data from their patients, and the financial support of Merck Sharp and Dohme Nederland N.V. Central Laboratory of the Netherlands Red Cross Blood Transfusion Service, Amsterdam.
T. E. W. FELTKAMP C. P. ENGELFRIET J. J. VAN LOGHEM.
HYPOCALCÆMIC FITS IN NEONATES SiR,ňThe concern of Dr. Baum and his colleagues (last week, p. 598) with the increased prevalence of hypocalcasmic fits in newborn infants is not peculiar to Hammersmith Hospital. In a local maternity unit, feeding infants on one part evaporated milk with two parts water, given ad lib from the first minutes of life, tetany by the end of the first week is becoming commonplace. This involves mature infants, regardless of sex, begins with irritability and rhythmical trembling, and may proceed to prolonged generalised convulsions. Substitution of’S.M.A.’ feeds restores health after a few days, but not without anxiety in individual cases, and administrative problems. It may be relevant that in another maternity unit, dealing with three times as many babies but feeding reconstituted dried cow’s milk with equal liberality, neonatal tetany remains exceptional. It does not seem likely that early exposure to a high phosphate load can be the whole explanation, and re-examination of the prevailing approach to feeding may well be desirable as your correspondents suggest. The Hull
Royal Infirmary, Hull, Yorkshire.
R.
J. PUGH.
SIR,-Iwas interested to read the letter by Dr. Baum and his colleagues. My own experience confirms their observation that there has been an increase in this condition in the past two to three years. Working in three different units during this period I can recall seeing a total of 7 cases since 1965, whereas in the preceding seven years, while working in much larger obstetric units, I can remember only about 4. Comparing notes with 2 pwdiatric registrars from other units a year or so ago, I remember that their impression was much the same. I had concluded that the increase was related to the decline in breast-feeding in the first week of life, and have said as much to midwives and medical students. It used to be the practice in most maternity units to assume that mothers would breast-feed (and indeed in some to insist on this), leaving those who felt inclined to change to dried milk after they went home. Infants appear to be vulnerable to the high phosphate content of cow’s milk only in the first two weeks or so of life: this may have prevented as many cases of neonatal tetany as we see now. The present practice in many units seems to be to ask the mother whether she wishes to breast-feed, and if the answer is in the negative to suppress lactation. This brings me to the second conclusion of your correspondents-namely, that too large a volume of cow’s milk is used in the first week of life. Here again I am in agreement with them. I have been surprised to find bottle-fed babies offered the full calculated 21/2 oz. per 50 calories per lb. on the second and third day of life. I was brought up on the " rule of sevens "-i.e., allowing 1/7 of the calculated requirements on the first day, 2/,th on the second, and so on, reaching the full amount at one week. Perhaps the recent emphasis on the high calorie requirements of the " small for dates " and low-birth-weight infants has led to confusion in the minds of midwives on the question of infant feeding generally. It is to be hoped that these latest observations from the Hammersmith unit will cause paediatricians to take a closer look at the feeding regimens in their maternity units. Incidentally, I should be interested to hear whether anyone