- Email: [email protected]
INVESTIGATION AND TREATMENT OF ENDOCRINOLOGICAL DISORDERS
434 a single exposure, and this is the practice which following in conjunction with our department hxmatology.
than
we
are
Radiotherapy Department, St. Thomas’s Hospital,
of
C. D. COLLINS.
London S.E.1.
SCABIES AND ACUTE GLOMERULONEPHRITIS SIR,-Although scabies might logically be expected to
give rise to acute glomerulonephritis as a result of secondary infection with a nephritogenic strain of p-hsmolytic streptococcus, as reported by Dr. Svartman and others (Jan. 29, p. 249), reports from temperate zones have been few. That it can occur in a climate as non-tropical as Edinburgh in winter is illustrated by the following case. A 17-year-old labourer in a knitwear factory first visited his doctor in late November, 1971, with pruritic infected lesions on his hands. The diagnosis of scabies was not made, and he was given antibiotics topically and systemically (including penicillin) and topical steroid ointments without improvement. When first seen at the hospital in January he had severe ecthymatous lesions of all his limbs, and on isolation of an acarus a diagnosis of secondarily infected scabies was made. He was treated immediately with benzyl benzoate and given chlortetracycline ointment to apply topically. A swab from one of the lesions grew a Phasmolytic streptococcus. A week later when seen again he had gross ankle oedema, albuminuria, and hsematuria, and obviously had acute glomerulonephritis. A throat-swab at that time grew no pathogen and he had not complained of a sore throat. a nephritogenic strain of well-known potential cause P-hsemolytic of acute glomerulonephritis, especially in young children,’ the infection resulting from scabies usually settles without treatment once the acarus has been eradicated, and attracts little attention. The greatest danger lies in missing the underlying diagnosis and allowing the right conditions for bacterial invasion of the skin to persist, but it would seem advisable to take a swab for culture from each case and, if a potentially dangerous organism is isolated, a short course of penicillin might avert disaster. Department of Dermatology,
Although impetigo due
to
streptococcus is
Royal Infirmary, Edinburgh EH3 9YW.
a
B. R. ALLEN.
DEVELOPMENTAL PÆDIATRICS SIR,-As one who has long laboured in the field of developmental pxdiatrics, may I endorse Professor Forfar’s contention (Feb. 5, p. 316) that " Developmental assessment, both of the normal and the abnormal, disorders of development, and diseases which disturb development all come within the ambit of developmental pxdiatrics " ? Also, may I strongly support his plea for further relevant training of students at undergraduate and postgraduate level ? I first had occasion to use this terminology myself at an inter-professional seminar on child care in 1954, when, in an attempt to resolve a somewhat acrimonious discussion, I found it necessary to explain the ways in which a paediatrician’s concepts and responsibilities with regard to developmental problems differed from those of the educational psychologists and the child-care officers who formed the majority of the study-group. At that time, the psychologists’ interests were mainly concentrated on problems of cognitive development and the predictive reliability of intelligence tests, while the social workers were greatly preoccupied with psychoanalytical theories regarding emotional
development. Fortunately, my explanation of developmental pxdiatrics
1.
Wannamaker, L. W. New Engl. J. Med. 1970, 282, 23.
proved acceptable, and I have continued to use the term ever since, with growing appreciation of its appropriateness. Quite recently, I was delighted to come across it, used with precisely the same meaning, in a book written at least twenty-five years ago by Arnold Gesell-that controversial genius, who, starting his professional career as a child psychologist, came to realise his need for further understanding of normal and abnormal developmental processes and ended up as a paediatrician. My own definition1 of the term is in complete accord with Professor Forfar’s. "
Developmental pxdiatrics is concerned with maturational (from fetal viability to full growth) in structure and function, of normal and abnormal children, for three purposes: first to promote optimal physical and mental health for all children in the community, second to ensure early diagnosis and appropriate treatment of developmental handicapping conditions of body, mind and personality, third to discover the cause, and ultimately the prevention of these handicapping conditions." processes
44 Regent’s Park Road, London NWl 7SX.
MARY D. SHERIDAN.
INVESTIGATION AND TREATMENT OF ENDOCRINOLOGICAL DISORDERS Sircan well understand the sense of frustration felt by Dr. Anderson and others (Jan. 8, p. 89). More widespread clinical use of hormone assays will not only lead to improved diagnosis and treatment for many sufferers but also to the discovery of new disease entities and to the correction of erroneous ideas about the nature of some endocrine disturbances. In the past, many advances in all branches of medicine have been made-and could only have been made-by chemists working alongside other specialists with close access to the patients. In the future too, it will still be the biochemists who will provide the facts required for the effective day-to-day treatment of some patients, and from which will stem new knowledge. Do Dr. Anderson and his colleagues appreciate this ? I am sadly disturbed that they do not seek to meet representatives of clinical biochemists together with those from the Department of Health to seek a remedy for this deficiency in the Health Service. Outside the world of the London teaching hospitals there are some biochemists who have almost forsaken their first love of "automation" for the subnanogram world of RIA. My own department, for example, now undertakes many of the steroid and polypeptide hormones analyses listed by Dr. Anderson and his colleagues. Surely the experience of those biochemists who already provide their clinical colleagues (surgeons, paediatricians, obstetriciansfgynaecologists, &c.) with all the help they require ought to be used to decide how best to fill the gap " between what is possible and what is available as regards
endocrinology ". I deplore very much a recent decision to set up three national " designated laboratories to do a single hormone estimation (urine chorionic gonadotrophin) for a screening "
service for choriocarcinoma. This decision followed meetings held between representatives of the Royal College of Physicians, the Royal College of Obstetricians and Gynaecologists, and the Department of Health. Neither the conduct nor the evaluation of the assay result for a urine output of human chorionic gonadotrophin needs more skill than can be provided by any district hospital consultant biochemist, given the necessary facilities. In my opinion what is needed is not 3 but 300 bio1. Sheridan, M. D. Hlth
Trends, 1969, 1, no. 2, p.4.
435
chemistry laboratories providing all but the least-used hormone services-i.e., 2 or 3 per present " region " or 1 for each of the new " areas ". Area Laboratory, King Edward VII Hospital, Windsor.
D. WATSON.
INTRAVASCULAR COAGULATION AND PRE-ECLAMPTIC TOXÆMIA SIR,—Dr. Wardle’s letter (Jan. 29, p. 262) expressing caution in interpreting measurements of urinary fibrin/
fibrinogen degradation products (F.D.P.) is welcome, but clarification. In particular, his statement that the filtration of fibrin/fibrinogen derivatives of molecular weight greater than 50,000 necessarily implies impaired selectivity is not correct. While the normal glomerulus filters plasma-proteinsand other macromolecules2 in a selective manner, high-molecular-weight proteins also pass across the normal glomerular basement membrane in man,3-6 and animals.7 Changes in the relative clearances of proteins of different molecular weights (i.e., selectivity)
requires
independent of the magnitude of the proteinuria, which in turn depends on the amount of protein presented to the glomerulus, the permeability of the basement membrane, and saturation of tubular reabsorptive sites.88 Like Dr. Preston (Jan. 1, p. 34), we have been unable to demonstrate abnormal F.D.P. excretion in patients with high serum concentrations of F.D.P. who have no renal damage, and there is increasing evidence that the presence of abnormal quantities of F.D.P. in the urine indicates renal glomerular disease. Thus, the findings of Rayner et al.9 that there was minimal clearance of infused high-molecularweight F.D.P. may merely indicate that his animals had normal kidneys. Further, it is possible that the techniques used by Bouma et al.10-12 are more sensitive for highermolecular-weight F.D.P. than the products of lower molecular weight. We have found abnormally high concentrations of urinary F.D.P. in patients whose protein selectivity indices vary from highly selective to non-selective, and the same holds true for low urine concentrations.13 Moreover, the relative concentrations of the various fragments found in different types of glomerular disease is independent of the protein selectivity. For example, in minimal lesion (highly selective) and membranous glomerulonephritis (unselective) the consistently low amounts of F.D.P. are excreted predominantly in the higher-molecular-weight forms to an extent dependent on the degree of proteinuria. As we have found no evidence of abnormal intrarenal fibrin deposition in these two conditions as assessed by electron and immunofluorescence microscopy, it seems likely that F.D.P. arise from fibrinogen filtered through the abnormally permeable basement membrane. The same phenomenon probably accounts for a small but limited portion of the F.D.P. excretion in proliferative forms of are
1. 2. 3. 4. 5. 6. 7. 8. 9.
10. 11.
12. 13.
Petrie, J. J. B., Cleland, J. F., MacLean, P. R., Robson, J. S. Clin. Sci. 1970, 39, 383. Hulme, B., Hardwicke, J. Proc. R. Soc. Med. 1966, 59, 509. Rowe, D. S., Soothill, J. F. Clin. Sci. 1961, 21, 75. Berggard, I. Clinica chim. Acta, 1961, 6, 413. Berggard, I., Cleve, H., Beam, A. G. ibid. 1964, 10, 1. MacLean, P. R., Robson, J. S. Clin. Sci. 1966, 30, 91. Farquhar, M. G., Wissig, S. L., Palade, G. E. J. exp. Med. 1961, 113, 47. Hardwicke, J., Squire, J. Clin. Sci. 1955, 14, 509. Rayner, H., Paraskevas, F., Israels, L. G., Israels, E. P. J. Lab. clin. Med. 1969, 74, 586. Bouma, B. N., Hedner, U., Nilsson, I. M. Scand J. clin. Lab. Invest. 1971, 27, 331. Larsson, S. O., Hedner, U., Nilsson, I. M. Scand. J. Urol. Nephrol. 1971, 5, 234. Carlsson, S., Hedner, U., Nilsson, I. M., Bergentz, S. E., Ljungqvist, U. Transplantation, 1970, 10, 366. Cash, J. D., Clarkson, A. R. Scand. J. Hœmatol. 1971, suppl. 13, p. 331.
glomerulonephritis, renal transplant rejection, and preeclamptic toxaemia, although the bulk of excreted derivatives are, in our experience, of the lower-molecular-weight variety. This predominance of fragments D and E occursregardless of the selectivity index, and bears no relation ta the total protein excretion or the degree of proteolytic activity in the urine. In proliferative diseases there is fibrin present within glomerular capillaries and the extent of F.D.P. excretion appears to be dependent on the amount of fibrin deposited (as judged by electron microscopy) and its intrarenal distribution (as judged by immunofluorescence). Moreover, certain forms of therapy are associated with reduction in intraglomerular fibrin and urinary F.D.P. excretion, the latter being due to disappearance of D and E fragments. This change in excretion pattern is not accompanied by a change in protein selectivity.14 While recognising the technical difficulties of conventional clearstudies with F.D.P., it is possible that when these can. be done the results may be hard to interpret. As with y-globulin, a spuriously high clearance may be found indisease states. Our results in pre-eclamptic toxaemia confirm those reported by Dr. Preston. Furthermore, serial studiesdemonstrate the same cyclical pattern of excretion observed previously in glomerulonephritis 15 and renal homotransplant rejection,16 which ceases soon after delivery. In particular, the urinary measurement has proved amore sensitive index of renal involvement than its serum
ance
counterpart. Medical Renal Unit, Department of Medicine, Royal Infirmary, Edinburgh EH3 9YW.
A. R. CLARKSON MARY K. MACDONALD A. M. DAVISON J. D. CASH J. S. ROBSON.
ILEOCOLITIS AFTER EXCHANGE TRANSFUSION
SIR,-Referring to the correspondence on this subject,. I wish to add my support to the view that most cases can be ascribed to obstruction of the superior-mesenteric venous blood-flow. It has been my practice for several monitor the to years position of all umbilical-vein catheters radiographically, whether used for exchange transfusion or not. Faulty placement of the catheter tip is quite common, the aim being to place the tip in the inferior vena cava or, failing this, at the origin of the left hepatic vein. It is particularly ominous if the catheter turns down into the portal vein and the superior mesenteric vein when the mechanical obstruction by the catheter is augmented by the injections under pressure of cold and acid blood. On four occasions, infants on slow umbilical infusions of dextrose through badly positioned catheters have developed the early features of ileocolitis-abdominal distension, bile-stained vomiting-and they have improved rapidly after removal or replacement of the catheter. A straight or lateral X-ray film of the abdomen to determine the position of the catheter before starting an exchange transfusion is by no means widely practised as an essential part of the routine technique. Until reported series of ileocolitis after umbilical-vein cannulation or exchange transfusion make specific reference to the radiographic position of the catheter tip in all cases, little credence can be attached to any
new
hypothesis.
Fulham Hospital, St. Dunstan’s Road, Hammersmith, London W.6.
HERBERT BARRIE.
14. Clarkson, A. R., Cash, J. D., Robson, J. S. Unpublished. 15. Clarkson, A. R., MacDonald, M. K., Petrie, J. J. B., Cash, J. D., Robson, J. S. Br. med. J. 1971, iii, 447. 16. Clarkson, A. R., Morton, J. B., Cash, J. D. Lancet, 1970, ii, 1220.
than
we
are
Radiotherapy Department, St. Thomas’s Hospital,
of
C. D. COLLINS.
London S.E.1.
SCABIES AND ACUTE GLOMERULONEPHRITIS SIR,-Although scabies might logically be expected to
give rise to acute glomerulonephritis as a result of secondary infection with a nephritogenic strain of p-hsmolytic streptococcus, as reported by Dr. Svartman and others (Jan. 29, p. 249), reports from temperate zones have been few. That it can occur in a climate as non-tropical as Edinburgh in winter is illustrated by the following case. A 17-year-old labourer in a knitwear factory first visited his doctor in late November, 1971, with pruritic infected lesions on his hands. The diagnosis of scabies was not made, and he was given antibiotics topically and systemically (including penicillin) and topical steroid ointments without improvement. When first seen at the hospital in January he had severe ecthymatous lesions of all his limbs, and on isolation of an acarus a diagnosis of secondarily infected scabies was made. He was treated immediately with benzyl benzoate and given chlortetracycline ointment to apply topically. A swab from one of the lesions grew a Phasmolytic streptococcus. A week later when seen again he had gross ankle oedema, albuminuria, and hsematuria, and obviously had acute glomerulonephritis. A throat-swab at that time grew no pathogen and he had not complained of a sore throat. a nephritogenic strain of well-known potential cause P-hsemolytic of acute glomerulonephritis, especially in young children,’ the infection resulting from scabies usually settles without treatment once the acarus has been eradicated, and attracts little attention. The greatest danger lies in missing the underlying diagnosis and allowing the right conditions for bacterial invasion of the skin to persist, but it would seem advisable to take a swab for culture from each case and, if a potentially dangerous organism is isolated, a short course of penicillin might avert disaster. Department of Dermatology,
Although impetigo due
to
streptococcus is
Royal Infirmary, Edinburgh EH3 9YW.
a
B. R. ALLEN.
DEVELOPMENTAL PÆDIATRICS SIR,-As one who has long laboured in the field of developmental pxdiatrics, may I endorse Professor Forfar’s contention (Feb. 5, p. 316) that " Developmental assessment, both of the normal and the abnormal, disorders of development, and diseases which disturb development all come within the ambit of developmental pxdiatrics " ? Also, may I strongly support his plea for further relevant training of students at undergraduate and postgraduate level ? I first had occasion to use this terminology myself at an inter-professional seminar on child care in 1954, when, in an attempt to resolve a somewhat acrimonious discussion, I found it necessary to explain the ways in which a paediatrician’s concepts and responsibilities with regard to developmental problems differed from those of the educational psychologists and the child-care officers who formed the majority of the study-group. At that time, the psychologists’ interests were mainly concentrated on problems of cognitive development and the predictive reliability of intelligence tests, while the social workers were greatly preoccupied with psychoanalytical theories regarding emotional
development. Fortunately, my explanation of developmental pxdiatrics
1.
Wannamaker, L. W. New Engl. J. Med. 1970, 282, 23.
proved acceptable, and I have continued to use the term ever since, with growing appreciation of its appropriateness. Quite recently, I was delighted to come across it, used with precisely the same meaning, in a book written at least twenty-five years ago by Arnold Gesell-that controversial genius, who, starting his professional career as a child psychologist, came to realise his need for further understanding of normal and abnormal developmental processes and ended up as a paediatrician. My own definition1 of the term is in complete accord with Professor Forfar’s. "
Developmental pxdiatrics is concerned with maturational (from fetal viability to full growth) in structure and function, of normal and abnormal children, for three purposes: first to promote optimal physical and mental health for all children in the community, second to ensure early diagnosis and appropriate treatment of developmental handicapping conditions of body, mind and personality, third to discover the cause, and ultimately the prevention of these handicapping conditions." processes
44 Regent’s Park Road, London NWl 7SX.
MARY D. SHERIDAN.
INVESTIGATION AND TREATMENT OF ENDOCRINOLOGICAL DISORDERS Sircan well understand the sense of frustration felt by Dr. Anderson and others (Jan. 8, p. 89). More widespread clinical use of hormone assays will not only lead to improved diagnosis and treatment for many sufferers but also to the discovery of new disease entities and to the correction of erroneous ideas about the nature of some endocrine disturbances. In the past, many advances in all branches of medicine have been made-and could only have been made-by chemists working alongside other specialists with close access to the patients. In the future too, it will still be the biochemists who will provide the facts required for the effective day-to-day treatment of some patients, and from which will stem new knowledge. Do Dr. Anderson and his colleagues appreciate this ? I am sadly disturbed that they do not seek to meet representatives of clinical biochemists together with those from the Department of Health to seek a remedy for this deficiency in the Health Service. Outside the world of the London teaching hospitals there are some biochemists who have almost forsaken their first love of "automation" for the subnanogram world of RIA. My own department, for example, now undertakes many of the steroid and polypeptide hormones analyses listed by Dr. Anderson and his colleagues. Surely the experience of those biochemists who already provide their clinical colleagues (surgeons, paediatricians, obstetriciansfgynaecologists, &c.) with all the help they require ought to be used to decide how best to fill the gap " between what is possible and what is available as regards
endocrinology ". I deplore very much a recent decision to set up three national " designated laboratories to do a single hormone estimation (urine chorionic gonadotrophin) for a screening "
service for choriocarcinoma. This decision followed meetings held between representatives of the Royal College of Physicians, the Royal College of Obstetricians and Gynaecologists, and the Department of Health. Neither the conduct nor the evaluation of the assay result for a urine output of human chorionic gonadotrophin needs more skill than can be provided by any district hospital consultant biochemist, given the necessary facilities. In my opinion what is needed is not 3 but 300 bio1. Sheridan, M. D. Hlth
Trends, 1969, 1, no. 2, p.4.
435
chemistry laboratories providing all but the least-used hormone services-i.e., 2 or 3 per present " region " or 1 for each of the new " areas ". Area Laboratory, King Edward VII Hospital, Windsor.
D. WATSON.
INTRAVASCULAR COAGULATION AND PRE-ECLAMPTIC TOXÆMIA SIR,—Dr. Wardle’s letter (Jan. 29, p. 262) expressing caution in interpreting measurements of urinary fibrin/
fibrinogen degradation products (F.D.P.) is welcome, but clarification. In particular, his statement that the filtration of fibrin/fibrinogen derivatives of molecular weight greater than 50,000 necessarily implies impaired selectivity is not correct. While the normal glomerulus filters plasma-proteinsand other macromolecules2 in a selective manner, high-molecular-weight proteins also pass across the normal glomerular basement membrane in man,3-6 and animals.7 Changes in the relative clearances of proteins of different molecular weights (i.e., selectivity)
requires
independent of the magnitude of the proteinuria, which in turn depends on the amount of protein presented to the glomerulus, the permeability of the basement membrane, and saturation of tubular reabsorptive sites.88 Like Dr. Preston (Jan. 1, p. 34), we have been unable to demonstrate abnormal F.D.P. excretion in patients with high serum concentrations of F.D.P. who have no renal damage, and there is increasing evidence that the presence of abnormal quantities of F.D.P. in the urine indicates renal glomerular disease. Thus, the findings of Rayner et al.9 that there was minimal clearance of infused high-molecularweight F.D.P. may merely indicate that his animals had normal kidneys. Further, it is possible that the techniques used by Bouma et al.10-12 are more sensitive for highermolecular-weight F.D.P. than the products of lower molecular weight. We have found abnormally high concentrations of urinary F.D.P. in patients whose protein selectivity indices vary from highly selective to non-selective, and the same holds true for low urine concentrations.13 Moreover, the relative concentrations of the various fragments found in different types of glomerular disease is independent of the protein selectivity. For example, in minimal lesion (highly selective) and membranous glomerulonephritis (unselective) the consistently low amounts of F.D.P. are excreted predominantly in the higher-molecular-weight forms to an extent dependent on the degree of proteinuria. As we have found no evidence of abnormal intrarenal fibrin deposition in these two conditions as assessed by electron and immunofluorescence microscopy, it seems likely that F.D.P. arise from fibrinogen filtered through the abnormally permeable basement membrane. The same phenomenon probably accounts for a small but limited portion of the F.D.P. excretion in proliferative forms of are
1. 2. 3. 4. 5. 6. 7. 8. 9.
10. 11.
12. 13.
Petrie, J. J. B., Cleland, J. F., MacLean, P. R., Robson, J. S. Clin. Sci. 1970, 39, 383. Hulme, B., Hardwicke, J. Proc. R. Soc. Med. 1966, 59, 509. Rowe, D. S., Soothill, J. F. Clin. Sci. 1961, 21, 75. Berggard, I. Clinica chim. Acta, 1961, 6, 413. Berggard, I., Cleve, H., Beam, A. G. ibid. 1964, 10, 1. MacLean, P. R., Robson, J. S. Clin. Sci. 1966, 30, 91. Farquhar, M. G., Wissig, S. L., Palade, G. E. J. exp. Med. 1961, 113, 47. Hardwicke, J., Squire, J. Clin. Sci. 1955, 14, 509. Rayner, H., Paraskevas, F., Israels, L. G., Israels, E. P. J. Lab. clin. Med. 1969, 74, 586. Bouma, B. N., Hedner, U., Nilsson, I. M. Scand J. clin. Lab. Invest. 1971, 27, 331. Larsson, S. O., Hedner, U., Nilsson, I. M. Scand. J. Urol. Nephrol. 1971, 5, 234. Carlsson, S., Hedner, U., Nilsson, I. M., Bergentz, S. E., Ljungqvist, U. Transplantation, 1970, 10, 366. Cash, J. D., Clarkson, A. R. Scand. J. Hœmatol. 1971, suppl. 13, p. 331.
glomerulonephritis, renal transplant rejection, and preeclamptic toxaemia, although the bulk of excreted derivatives are, in our experience, of the lower-molecular-weight variety. This predominance of fragments D and E occursregardless of the selectivity index, and bears no relation ta the total protein excretion or the degree of proteolytic activity in the urine. In proliferative diseases there is fibrin present within glomerular capillaries and the extent of F.D.P. excretion appears to be dependent on the amount of fibrin deposited (as judged by electron microscopy) and its intrarenal distribution (as judged by immunofluorescence). Moreover, certain forms of therapy are associated with reduction in intraglomerular fibrin and urinary F.D.P. excretion, the latter being due to disappearance of D and E fragments. This change in excretion pattern is not accompanied by a change in protein selectivity.14 While recognising the technical difficulties of conventional clearstudies with F.D.P., it is possible that when these can. be done the results may be hard to interpret. As with y-globulin, a spuriously high clearance may be found indisease states. Our results in pre-eclamptic toxaemia confirm those reported by Dr. Preston. Furthermore, serial studiesdemonstrate the same cyclical pattern of excretion observed previously in glomerulonephritis 15 and renal homotransplant rejection,16 which ceases soon after delivery. In particular, the urinary measurement has proved amore sensitive index of renal involvement than its serum
ance
counterpart. Medical Renal Unit, Department of Medicine, Royal Infirmary, Edinburgh EH3 9YW.
A. R. CLARKSON MARY K. MACDONALD A. M. DAVISON J. D. CASH J. S. ROBSON.
ILEOCOLITIS AFTER EXCHANGE TRANSFUSION
SIR,-Referring to the correspondence on this subject,. I wish to add my support to the view that most cases can be ascribed to obstruction of the superior-mesenteric venous blood-flow. It has been my practice for several monitor the to years position of all umbilical-vein catheters radiographically, whether used for exchange transfusion or not. Faulty placement of the catheter tip is quite common, the aim being to place the tip in the inferior vena cava or, failing this, at the origin of the left hepatic vein. It is particularly ominous if the catheter turns down into the portal vein and the superior mesenteric vein when the mechanical obstruction by the catheter is augmented by the injections under pressure of cold and acid blood. On four occasions, infants on slow umbilical infusions of dextrose through badly positioned catheters have developed the early features of ileocolitis-abdominal distension, bile-stained vomiting-and they have improved rapidly after removal or replacement of the catheter. A straight or lateral X-ray film of the abdomen to determine the position of the catheter before starting an exchange transfusion is by no means widely practised as an essential part of the routine technique. Until reported series of ileocolitis after umbilical-vein cannulation or exchange transfusion make specific reference to the radiographic position of the catheter tip in all cases, little credence can be attached to any
new
hypothesis.
Fulham Hospital, St. Dunstan’s Road, Hammersmith, London W.6.
HERBERT BARRIE.
14. Clarkson, A. R., Cash, J. D., Robson, J. S. Unpublished. 15. Clarkson, A. R., MacDonald, M. K., Petrie, J. J. B., Cash, J. D., Robson, J. S. Br. med. J. 1971, iii, 447. 16. Clarkson, A. R., Morton, J. B., Cash, J. D. Lancet, 1970, ii, 1220.