AORTOGRAPHY FOR PERIPHERAL ARTERIAL DISEASE

208 U.S.S.R. is "for all intents and purposes, of similar military potential to that of the U.S.A." Jane’s Fighting Ships has opined differently, indicating that the Russian navy is of such size and strength as to exceed any legitimate defence need. It is thus intended for offensive war. Barnaby states there is "so much military power on each side that quite large differences are meaningless in military terms". That was the conventional wisdom lulling Allied leaders 40 years ago before the difference turned France into part of Festung Europa and the Battle of Britain began. General Sir John Hackett and other top-ranking NATO generals have written The Third World War: August 1985. Once again, unilateral armament policies almost do Europe in again. So far, the book’s only inaccuracy in early 1980 "history" is that Egypt and Iran are on different terms with the U.S.A. than is currently the case. We do not hear anything from Barnaby or the wearisome Stockholm International Peace Research Institute about gaining Russian cooperation for a real commitment to peaceagreement to international nuclear weapons inspection, for instance. Obtain some genuine agreement on problems of that nature and no pressures for weapons expenditures will be able to stop subsequent peace actions. Your accompanying editorial notes President Eisenhower’s comments about the military-industrial complex. In fairness, you should also remind your readers that Eisenhower also said: "Until war is eliminated from international relations, unpreparedness for it is well nigh as criminal as war itself." 1616 King Street, La Crosse, Wisconsin 54601, U.S.A.

JOHN B. WEETH

LUMBAR PUNCTURE IN CHILDREN WHO HAVE HAD FEVER AND A CONVULSION

SIR,-Like Dr Vincent (May 31) and Professor Finley and Goldenring (July 12) I disagree with the oft expressed view that a lumbar puncture is normally unnecessary when an infant or young child has a major convulsion associated with Dr

fever. I agree with Ouelette that a lumbar puncture should be done on all children having their first febrile fit under two years of age. Two recent British textbooks=·3express a similar view. By far the most important cause of medical disasters is overconfidence. I guess that there are few experienced peediatricians who have not repeatedly seen tragedies resulting from overconfidence in discarding a diagnosis of meningitis in infants and small children. 8 Harley Road, Sheffield S11 9SD

RONALD ILLINGWORTH

SIR,-Professor Lorber and Dr Sutherland should supply further clinical details of the children in whom cerebellar coning developed after lumbar puncture following a convulsion in association with meningitis. In particular, was papilloedema definitely absent, were congenital abnormalities of the brain present (notably, those involving the posterior fossa), and might meningitis have been missed for a few days while antibiotics were given, with the possibility that basal adhesions had caused internal hydrocephalus? If these contingencies were not present perhaps Lorber and Sutherland would like to suggest why cerebellar coning occurred in their patients and how it might be avoided in future in children in whom meningitis seems

likely.

University Hospital of Wales, Heath Park, Cardiff CF4 4XW

SHEILA J. WALLACE

1. Ouelette EM. The child who convulses with fever. Pediat Clin North Am

1974, 21: 467.

Pædiatric emergencies. London: Butterworths, 1979: 354. 3. Wallace SJ. In: Rose FC, ed. Pædiatric neurology. Oxford: Blackwell Scientific Publications, 1979: 352.

2. Black JA.

AORTOGRAPHY FOR PERIPHERAL ARTERIAL DISEASE SiR,—Mr Macpherson and his colleagues (July 12, p. 80) ask "Is aortography abused in lower limb ischsemia?" It was disappointing that these workers relied solely upon clinical findings as an indication for aortography and omitted any measurement of blood pressure and flow.

They report on a series of 82 aortograms done because of suspected peripheral vascular disease. These aortograms led to only 22 arterial reconstructions, the implication being that many were unnecessary. Macpherson et al. show that this arteriography/surgery ratio of 3-7 could have been dramatically reduced had the patients been referred to a vascular surgeon before aortography. They found 40 patients in whom they felt the investigation was justified, and a further 1 in whom it was probably justified. This grouping would lead to an arteriography ratio of only 2.3-a figure in close agreement with our experience of vascular referrals between 1965 and 1970, where our arteriography/surgery ratio was 2-5. However, our experience since then suggests that objective measurements of vascular function can supplement clinical-judgment and reduce this ratio even further.

We found that the patients’ estimated claudication distance has no relevance to the measured distance as determined on a treadmill.’ Similarly, Strandness has reported2that "the surgeon’s hand and the information obtained from aortography are but crude measurements of the hxmodynamic process that are continually occurring in the cardiovascular system". In the patient who has multisegmental disease, aortography fails to reveal the hxmodynamically significant segment. Therefore, we need objective measurements. ...

In our vascular laboratory, in a series of over 2000 patients, it has been possible to reduce3 the number of aortograms done for each arterial procedure carried out from 2-5to 1 1. In the investigation of suspected extracranial arterial disease we have also dramatically reduced the numbers of carotid arteriograms. Of greater importance, we believe we have improved patient management. Since 1974 we have recorded blood pressure and flows in the leg arteries using continuous wave ultrasound, and measured the maximum walking distance on a treadmill. This has enabled us to diagnose avascular claudicants and to assess the site and severity of arterial stenoses. These simple measurements of function are non-invasive, quick to perform, and, above all, safe; they provide a baseline and can be repeated to show progression or spontaneous improvement of a patient’s arterial disease. From these measurements the patient’s progress can be predicted with a high degree of success,4 and we believe we can thus detect those patients "in whom operation would be impossible because of severe distal disease". It is likely, therefore, that had Macpherson and his colleagues used these objective measurements to supplement their clinical acumen they might have been able to reduce the aortograms performed to only 25 (all of which were in their group 1), giving them an arteriography/surgery ratio of 1.1, which our experience suggests is possible. In these times of national

austerity it is comforting to know Strandness remarked,5 "the basic vascular laboratory equipment is cheap to purchase and maintain". While endorsing this remark we would add that it is also easy to use. Our that,

as

1. Thomas M, Quick DRG. Intermittent claudication. Br Med J 1976; i: 1531. 2. Strandness, DE. Penpheral arterial disease. London: Churchill, 1969. 3. Roberts VC, Berlyn DJ, Cotton LT. Ultrasonic Blood Velocunetry—a cost effective alternative to artenography in the selection of patients for reconstructive surgery. Proc IVth Nordic Conf Med and Biol Eng. 1977. Copenhagen: 47. 4. Fulton T, Roberts VC. In: Haemodynamics of Limbs II. A hierarchical test structure for the diagnosis of peripheral arterial disease, ed. Puel P, Boccalon H, Enjalbert A. Toulose (in press). 5. Strandness DE. Use and abuse of the Vascular Laboratory in Surgical Clinics of Nth. Am. 1979. Vol. 59, No. 4.

209

experience suggests6 that the capital costs of establishing a vascular laboratory are more than offset by the savings made by reducing the number of arteriograms. In 1978, with a load of 500 new patients, we believed our laboratory to be saving 200 arteriograms a year. Our local costs indicated that these would have cost about ,25 000. The costs attributable to running the vascular laboratory were then ;15 000, so our savings almost equalled the running costs. In conclusion, we endorse Macpherson and colleagues’ view that the numbers of arteriograms could be greatly reduced. However, we believe that the widespread use of objective measurements by vascular surgeons could reduce still further the numbers of aortograms performed and, most importantly, improve patient management. M. E. J. HANCOCK Biomedical

Engineering Department, King’s College Hospital Medical School,

Dulwich Hospital, London SE22 8PT

W. A. P. HAMILTON J. GRAHAM L. T. COTTON

FETAL MOVEMENTS DURING PREGNANCY

SIR,-Since several publications have reported on the counting of fetal movements (FM) and its value as monitor of fetal wellbeingl-4 we have examined FMs in 212 women seen consecutively either in the open ward during their normal pregnancies (96) or admitted to hospital because of complications (116). The expected dates of confinement were certain. The

women

counted the number of FM for half an hour

morn-

6. Roberts VC.—et al. In: Haemodynamics of the Limbs. The Clinical Vascular Laboratory and its role in the management of peripheral vascular diseases, 1979. ed. Puel P, Boccalon H, Enjalbert A. Toulose: p. 519. 1979. 1. Ehrström, C. Fetal movement monitoring in normal and high-risk pregnancy. Acta Obstet Gynecol Scand 1979; suppl. 80: 1-32. 2. Pearson JF, Weaver JB. Fetal activity and fetal wellbeing: an evaluation. Br Med J 1976; i: 1305-07. 3. Sadovsky E, Yaffe H. Daily fetal movement recording and fetal prognosis. Obstet Gynecol 1973; 41: 845-50. 4. Sadovsky E, Yaffe H, Polishuk WZ. Fetal movements in pregnancy and urinary estriol in prediciton of impending fetal death in utero. Israel J Med Sci 1974, 10: 1096-99.

Fig. I-FM counts: both sexes. onna1: F=3.43, df 18/714 (p<0.01), F.Bt counted

over

828 weeks.

Abnormal: F=1.75, df 18/1,198 (p<0.05), F.BB counted

over

1332

days.

noon, and evening, and the number of movements were converted to number of movements-per 12 h. The daily mean in a week was used in the statistical calculations. All the children in the normal group were healthy at birth, but in the abnormal group there was 1 stillbirth, 2 deaths within 12 h of birth, 8 cases of dysmaturity, and 1 case of diabetic embryopathy. 2 children showed cerebral irritation and 4 had asphyxia; all 6 recovered completely within 48 h. The rest of the children were normal. Analysis was rendered difficult by the great variation in FMs within individual women and the even greater variation in counts between women. Logarithms of FMs were used in the calculations, and figs. 1-3 show the geometric means. The differences of the level of counting were corrected for by calculating the deviations from the women’s level of counting instead of using absolute values. An analysis of variance was used to estimate the variation between the weekly mean of FM and the within-variation. For the weekly mean degrees of freedom were number of weeks minus one, and for the within-variation number of countings minus number of weeks minus number of patients plus one. If the F-test showed p<0.01, the variation from week to week was accepted as significant. The weekly mean of counts was a parabola explained by a quadratic

ing,

equation.

Fig. 1 shows the mean of FM per 12 h related to postmenstrual weeks. The decrease of FM towards term in the normal pregnancies might be due to decreasing space and/or increasing inhibition from the maturing central nervous system.5 The decreasing FM in complicated pregnancies could be caused by the complications or by admission and maternal bed-rest improving the condition of the fetus and making it more lively; the difference could also be caused by the different conditions under which the FM were recorded at home and in hospital. Both in normal and in complicated pregnancies female and male fetuses showed different activities (figs. 2 and 3). We cannot explain this. Big differences within individuals mean that FM counts cannot be used for prenatal sex determination. 5. Mathews DD. Fetal well-being in gravidas with diminished fetal term. Obstet Gynecol 978; 51: 281-3.

activity

at

Fig. 2-FM counts: females.

Fig. 3-FM counts: males.

Normal F=2.52, df 18/287 (p<0.01), FM counted over 478 weeks. Abnormal: F=test 3.71, df 18/460 (p<0.01), FM counted over 528 days.

Normal: F=3.39, df 18/409 (p<0.01), FM counted over 478 weeks. Abnormal: F=test 2.84, df 16/709 (p<0.01), FM counted over 785 days.