- Email: [email protected]
MR. IRVINE'S BILL
343
ing data on this point,25 however, the impurity of the renin preparations used for immunisation must throw some doubt on the specificity of this effect. In the same way the specificity of the recently described phospholipid inhibitor of the action of renin on its substrate reaction in relieving experimental renal hypertension 26-28 is yet to be established. 29 Much interest therefore surrounds the study of the animal immunised against synthetic angiotensin 11. Such an animal has been found to be specifically unresponsive to infusions of angiotensin 11 which are pressor in the normal rabbit,2O and there are now several reports on the effect of such immunisation on renal hypertension. In the rat, preliminary results are contradictory. HEDWALL 30 was unable to influence renal-clip hypertension in this species by passive transfer of antiserum, but CHRlSTLlEB et al.31 have found a definite though variable fall in bloodpressure after active immunisation. In these latter studies, however, antibody titres were low and correlated poorly with the degree of blood-pressure fall; and these findings, together with a failure to obtain a complete abolition of pressor response to exogenous angiotensin II in these animals, must cast some doubt on the specificity of the bloodpressure fall. In HEDWALL’S study 30 too, immunisation caused only partial inhibition of the angiotensin pressor effect, and so further investigation is needed in this species. In rabbits, EIDE and AARs 32 were unable to prevent the development of a perinephritic type of hypertension in spite of effective immunisation against angiotensin 11. Hypertension in these experiments was induced by renal encapsulation in silk soaked in turpentine, and the relationship of this form of hypertension to that associated with renal-artery clipping or renal-artery stenosis is by no means clear. The report from St. Mary’s Hospital, London, on p. 333 of this issue is therefore of interest. It shows that hypertension could be induced in the rabbit by the usual technique of renal-artery clipping with contralateral nephrectomy, despite effective and specific in-vivo angiotensin-n blockade by immunisation. Further, once estabushed in the non-immune rabbit, this form of hypertension was not reversible
by subsequent angiotensin-ll immunisation, whereas removal of the renal-artery clip caused a rapid fall in blood-pressure to approximately normal levels. These results are important. They will of course need confirmation, but the effectiveness and specificity 25.
Weiser, R. A., Johnson, A. G., Hoobler, S. W. Lab. Invest. 1969, 20, 326. 26. Sen, S., Smeby, R. R., Bumpus, F. M. Biochemistry, Wash. 1967, 6, 1572. 27. Sen, S., Smeby, R. R., Bumpus, F. M. Am. J. Physiol. 1968, 214, 337.
28. 29. 30. 31.
Sen, S., Smeby, R. R., Bumpus, F. M. ibid. 1969, 216, 499. Circulation, 1969, 40, 739. Hedwall, P. R. Br. J. Pharmacol. 1968, 34, 623. Christlieb, A. R., Biber, T. U. L., Hickler, R. B. J. clin. Invest. 1969,
32.
48, 1506. Eide, I., Aars, H. Nature, Lond. 1969, 222,
571.
of
blockade in the experiments make it very hard to sustain the idea that circulating angiotensin 11 is the sole or indeed even the major factor in this form of hypertension.
angiotensin
MR. IRVINE’S BILL
THE Abortion Act 1967, shortly to complete its second year in action, faces scrutiny again in the House of Commons this week when Mr. Bryant Godman Irvine presents a reforming Bill. If the Bill is ultimately passed, a lawful abortion may then be performed only " by or under the supervision of a consultant gynxcologist in the National Health Service or a medical practitioner of equivalent status approved by the Secretary of State for Social Services " for that purpose. And the medical practitioner carrying out or supervising the operation would have to be one of the two medical practitioners required by the Act to form an opinion that an abortion was necessary. A Bill unsuccessfully presented by Mr. St. John-Stevas last July also sought to restrict the performance or supervision of abortions to N.H.S. consultant gynxcologists (or their supervised deputies) or to those of " equivalent status ".
If Mr. Godman Irvine wins where Mr. St. JohnStevas lost, then the Secretary of State has an unanswerable question on his desk. Who shall be of " equivalent status " ? Perhaps someone who is M.R.C.O.G. or F.R.C.S.-or D.OBST. ? Or someone who has been practising gynxcology for five years ? Or ten years ? The Bill requires a Minister to assess the capability of a doctor to act in a certain situation. It is therefore odd that the Bill comes forward with the support of the British Medical Association written into its explanatory memorandum, since the Association has long trembled at such intrusion on professional freedom. One aim of the Bill’s supporters is to restrain the activities of those doctors who make great profit from legal abortions performed outside the N.H.S., who encourage patients to come from abroad, and who operate in private clinics which do not always provide adequate care. The publicity rightly given to unsatisfactory nursing-homes and bad treatment have partly obscured the benefits of the 1967 Act. Many will dispute, however, the assessment1 that the Act is working satisfactorily; and criticism is hard to counter completely until more facts are known, particularly those concerning the rise or fall in criminal abortion. Nevertheless, Mr. Irvine’s Bill is out of place. What difference can it really make ? Few of the abusing doctors will be excluded from the market by legislation which requires a Government department to pronounce that they are, or are not, of " equivalent status ". Perhaps, under cover of this device, some supporters of the Bill are now renewing a long-rooted opposition to reform. However that may be, Parliament can never provide the public with complete protection against discreditable money-makers. Since no amount of inspection of nursing-homes by the 1.
Diggory, P., Peel, J., Potts,
M. Lancet, Feb. 7, 1970,
p. 287.
344
Department of Health can correct all the faults, the profession must do more to curb its wayward members. "One of the functions of the General Medical Council is to demonstrate that the code of medical ethics is something outside and, in a sense, more powerful than the Law. If minimum standards are to be secured, then this task is for the G.M.C. rather than the House of Commons. "2
INTENSIVE CARE OF THE NEWBORN IN view of the increase in intensive-care units for the newborn and their heavy demands on skilled staff and complex equipment, an immediate question is whether such units can be justified in terms of reduced mortality in low-birth-weight infants of 1000-2500 g. growing evidence that they can. For example, at the Jefferson Davis Hospital, Houston, Texas,33 the mortality in low-birth-weight infants of 1000-2500 g. has fallen to 5-5%. A significant reduction in mortality since establishing an intensive-care unit has been confirmed by Mildred T. Stahlman, who, moreover found no difference in the development quotients between survivors of severe hyaline-membrane disease, many of whom had required respirator treatment, and their own normal siblings. Reviewing respirator-treated cases of hyalinemembrane disease at the Toronto Hospital for Sick Children, Paul R. Swyer3 predicted a 13% reduction in the mortality of the disease and found an actual reduction of 18%with ventilator care. As for the relative merits of positive and negative ventilators, perhaps the type of instrument has less influence on the outcome than the organisation behind it. Nevertheless, no-one who cares for these children can fail to be impressed by a survival-rate of 59% among infants ventilated by intermittent negative pressure.4 Discussing pulmonary oxygen toxicity, N. M. Nelson remarked that, since the normal fetal arterial oxygen tension is only 25 mm. Hg, it is unrealistic to attempt to attain levels of 75-150 in ventilated newborn babies. Negative-pressure ventilators have never been associated with pulmonary fibroplasia attributable to Prolonged positive-pressure ventilation in oxygen. infants with high airways resistance has been associated with over-inflated lungs.&a cute; Has gastrostomy feeding any place in the intensive care of small premature infants ? M. Comblath3 described a controlled study of high-risk babies weighing between 750 and 1250 g. at birth: in a sequential analysis of matched pairs, mortality was higher with gastrostomy than with routine naso-
gastric-tube feeding. Intensive care of the newborn usually means cannulation of the umbilical artery and vein for Thus, given monitoring and infusion purposes. suitable equipment, measurements of arterial and central venous pressures are possible without any more 2. ibid. 1969, ii, 148. 3. Problems of Neonatal Intensive Care Units. Report of 59th Ross Conference on Pediatric Research ’edited by J. F. Lucey). Ross Laboratories, Columbus, Ohio, 1969. 4. Stern, L. 78th Annual Meeting, American Pædiatric Society, 1968. 5. Barnes, N. D., Glover, W. J., Hull, D., Milner, A. D. Lancet, 1969, ii, 1096.
disturbance of the infant. R. H. Phibbsfound bloodpressure measurements clinically useful in hydrops, massive blood-loss, birth trauma, and birth asphyxia, and he used whole blood or albumin to correct hypotension. Describing the hazards of umbilical-vessel cannulation, L. S. James3 recommended that X-ray films should always be taken to check the position of catheters, especially those used for infusion of alkali. Occasional instances of infection, accidental hxmorrhage, perforation, and vascular occlusion are disquieting complications of a method of management for which there is no convenient substitute, although more use could be made of peripheral veins and heel blood specimens. Summing up, J. F. Lucey3 pointed out that intensive care is not just a matter of buying a respirator or a blood-gas analyser: the key elements are people who care intensively ". "
SUDDEN UNEXPECTED DEATH SUDDEN death commonly relates to coronary and cerebral vascular disease in the older age-groups, but a report6 from Gainsville, Florida, diverts attention to unexpected death in youth. A 15-year-old boy collapsed and died after a 100-yard sprint. A few hours later his 14-year-old sister fainted and died on hearing of her brother’s death, ventricular fibrillation being recorded. A year earlier another sister had died at age 10 while playing on a beach. In two generations of this family four other instances of sudden unexpected death under the age of 17 years were discovered, with three further cases in their early forties. There was no history of overt heart-disease but, of those dying, eight had had previous episodes of fainting associated with emotion. Post-mortem examination in four children between 6 and 16 years showed no gross abnormality of the heart, but serial sectioning revealed a hypoplastic conduction system in the heart of the boy sprinter and his sister. The atrioventricular node was indistinct and in the boy the right bundle branch had a number of blind-ended ramifications without insertion into the ventricular myocardium. The nodal artery was absent. His sister had a very small right bundle. Sudden death in youth is well recognised in various cardiac anomalies including aortic-valve stenosis, idiopathic hypertrophic suboartic stenosis, and rarer familial conduction disturbances evident in the resting electrocardiogram.7 In the two patients described by Green et al.,6 however, clinical, radiological, and electrocardiographic examinations were normal 2 weeks (the boy) and 1 year (the girl) before death. The degree to which a defective conduction system predisposes to arrhythmias is unknown, and facts are hard to establish. The findings in children with rare conduction anomalies might well be relevant to sudden unexpected death at older ages. Ischsemic degeneration of conduction tissues can lead to deviation of pathways of electrical activation, and this may be associated with electrical instability and arrhythmias 8 under Green, R., Korovetz, M. J., Shanklin, D. R., Devito, J. J., Taylor, W. J. Archs intern. Med. 1969, 124, 359. 7. Jervell, A., Lange-Nielsen, F. Am. Heart J. 1957, 54, 59. 8. Hinkle, L. E., Carver, S. T., Stevens, M. Am. J. Cardiol. 1969, 24, 629.
6.
ing data on this point,25 however, the impurity of the renin preparations used for immunisation must throw some doubt on the specificity of this effect. In the same way the specificity of the recently described phospholipid inhibitor of the action of renin on its substrate reaction in relieving experimental renal hypertension 26-28 is yet to be established. 29 Much interest therefore surrounds the study of the animal immunised against synthetic angiotensin 11. Such an animal has been found to be specifically unresponsive to infusions of angiotensin 11 which are pressor in the normal rabbit,2O and there are now several reports on the effect of such immunisation on renal hypertension. In the rat, preliminary results are contradictory. HEDWALL 30 was unable to influence renal-clip hypertension in this species by passive transfer of antiserum, but CHRlSTLlEB et al.31 have found a definite though variable fall in bloodpressure after active immunisation. In these latter studies, however, antibody titres were low and correlated poorly with the degree of blood-pressure fall; and these findings, together with a failure to obtain a complete abolition of pressor response to exogenous angiotensin II in these animals, must cast some doubt on the specificity of the bloodpressure fall. In HEDWALL’S study 30 too, immunisation caused only partial inhibition of the angiotensin pressor effect, and so further investigation is needed in this species. In rabbits, EIDE and AARs 32 were unable to prevent the development of a perinephritic type of hypertension in spite of effective immunisation against angiotensin 11. Hypertension in these experiments was induced by renal encapsulation in silk soaked in turpentine, and the relationship of this form of hypertension to that associated with renal-artery clipping or renal-artery stenosis is by no means clear. The report from St. Mary’s Hospital, London, on p. 333 of this issue is therefore of interest. It shows that hypertension could be induced in the rabbit by the usual technique of renal-artery clipping with contralateral nephrectomy, despite effective and specific in-vivo angiotensin-n blockade by immunisation. Further, once estabushed in the non-immune rabbit, this form of hypertension was not reversible
by subsequent angiotensin-ll immunisation, whereas removal of the renal-artery clip caused a rapid fall in blood-pressure to approximately normal levels. These results are important. They will of course need confirmation, but the effectiveness and specificity 25.
Weiser, R. A., Johnson, A. G., Hoobler, S. W. Lab. Invest. 1969, 20, 326. 26. Sen, S., Smeby, R. R., Bumpus, F. M. Biochemistry, Wash. 1967, 6, 1572. 27. Sen, S., Smeby, R. R., Bumpus, F. M. Am. J. Physiol. 1968, 214, 337.
28. 29. 30. 31.
Sen, S., Smeby, R. R., Bumpus, F. M. ibid. 1969, 216, 499. Circulation, 1969, 40, 739. Hedwall, P. R. Br. J. Pharmacol. 1968, 34, 623. Christlieb, A. R., Biber, T. U. L., Hickler, R. B. J. clin. Invest. 1969,
32.
48, 1506. Eide, I., Aars, H. Nature, Lond. 1969, 222,
571.
of
blockade in the experiments make it very hard to sustain the idea that circulating angiotensin 11 is the sole or indeed even the major factor in this form of hypertension.
angiotensin
MR. IRVINE’S BILL
THE Abortion Act 1967, shortly to complete its second year in action, faces scrutiny again in the House of Commons this week when Mr. Bryant Godman Irvine presents a reforming Bill. If the Bill is ultimately passed, a lawful abortion may then be performed only " by or under the supervision of a consultant gynxcologist in the National Health Service or a medical practitioner of equivalent status approved by the Secretary of State for Social Services " for that purpose. And the medical practitioner carrying out or supervising the operation would have to be one of the two medical practitioners required by the Act to form an opinion that an abortion was necessary. A Bill unsuccessfully presented by Mr. St. John-Stevas last July also sought to restrict the performance or supervision of abortions to N.H.S. consultant gynxcologists (or their supervised deputies) or to those of " equivalent status ".
If Mr. Godman Irvine wins where Mr. St. JohnStevas lost, then the Secretary of State has an unanswerable question on his desk. Who shall be of " equivalent status " ? Perhaps someone who is M.R.C.O.G. or F.R.C.S.-or D.OBST. ? Or someone who has been practising gynxcology for five years ? Or ten years ? The Bill requires a Minister to assess the capability of a doctor to act in a certain situation. It is therefore odd that the Bill comes forward with the support of the British Medical Association written into its explanatory memorandum, since the Association has long trembled at such intrusion on professional freedom. One aim of the Bill’s supporters is to restrain the activities of those doctors who make great profit from legal abortions performed outside the N.H.S., who encourage patients to come from abroad, and who operate in private clinics which do not always provide adequate care. The publicity rightly given to unsatisfactory nursing-homes and bad treatment have partly obscured the benefits of the 1967 Act. Many will dispute, however, the assessment1 that the Act is working satisfactorily; and criticism is hard to counter completely until more facts are known, particularly those concerning the rise or fall in criminal abortion. Nevertheless, Mr. Irvine’s Bill is out of place. What difference can it really make ? Few of the abusing doctors will be excluded from the market by legislation which requires a Government department to pronounce that they are, or are not, of " equivalent status ". Perhaps, under cover of this device, some supporters of the Bill are now renewing a long-rooted opposition to reform. However that may be, Parliament can never provide the public with complete protection against discreditable money-makers. Since no amount of inspection of nursing-homes by the 1.
Diggory, P., Peel, J., Potts,
M. Lancet, Feb. 7, 1970,
p. 287.
344
Department of Health can correct all the faults, the profession must do more to curb its wayward members. "One of the functions of the General Medical Council is to demonstrate that the code of medical ethics is something outside and, in a sense, more powerful than the Law. If minimum standards are to be secured, then this task is for the G.M.C. rather than the House of Commons. "2
INTENSIVE CARE OF THE NEWBORN IN view of the increase in intensive-care units for the newborn and their heavy demands on skilled staff and complex equipment, an immediate question is whether such units can be justified in terms of reduced mortality in low-birth-weight infants of 1000-2500 g. growing evidence that they can. For example, at the Jefferson Davis Hospital, Houston, Texas,33 the mortality in low-birth-weight infants of 1000-2500 g. has fallen to 5-5%. A significant reduction in mortality since establishing an intensive-care unit has been confirmed by Mildred T. Stahlman, who, moreover found no difference in the development quotients between survivors of severe hyaline-membrane disease, many of whom had required respirator treatment, and their own normal siblings. Reviewing respirator-treated cases of hyalinemembrane disease at the Toronto Hospital for Sick Children, Paul R. Swyer3 predicted a 13% reduction in the mortality of the disease and found an actual reduction of 18%with ventilator care. As for the relative merits of positive and negative ventilators, perhaps the type of instrument has less influence on the outcome than the organisation behind it. Nevertheless, no-one who cares for these children can fail to be impressed by a survival-rate of 59% among infants ventilated by intermittent negative pressure.4 Discussing pulmonary oxygen toxicity, N. M. Nelson remarked that, since the normal fetal arterial oxygen tension is only 25 mm. Hg, it is unrealistic to attempt to attain levels of 75-150 in ventilated newborn babies. Negative-pressure ventilators have never been associated with pulmonary fibroplasia attributable to Prolonged positive-pressure ventilation in oxygen. infants with high airways resistance has been associated with over-inflated lungs.&a cute; Has gastrostomy feeding any place in the intensive care of small premature infants ? M. Comblath3 described a controlled study of high-risk babies weighing between 750 and 1250 g. at birth: in a sequential analysis of matched pairs, mortality was higher with gastrostomy than with routine naso-
gastric-tube feeding. Intensive care of the newborn usually means cannulation of the umbilical artery and vein for Thus, given monitoring and infusion purposes. suitable equipment, measurements of arterial and central venous pressures are possible without any more 2. ibid. 1969, ii, 148. 3. Problems of Neonatal Intensive Care Units. Report of 59th Ross Conference on Pediatric Research ’edited by J. F. Lucey). Ross Laboratories, Columbus, Ohio, 1969. 4. Stern, L. 78th Annual Meeting, American Pædiatric Society, 1968. 5. Barnes, N. D., Glover, W. J., Hull, D., Milner, A. D. Lancet, 1969, ii, 1096.
disturbance of the infant. R. H. Phibbsfound bloodpressure measurements clinically useful in hydrops, massive blood-loss, birth trauma, and birth asphyxia, and he used whole blood or albumin to correct hypotension. Describing the hazards of umbilical-vessel cannulation, L. S. James3 recommended that X-ray films should always be taken to check the position of catheters, especially those used for infusion of alkali. Occasional instances of infection, accidental hxmorrhage, perforation, and vascular occlusion are disquieting complications of a method of management for which there is no convenient substitute, although more use could be made of peripheral veins and heel blood specimens. Summing up, J. F. Lucey3 pointed out that intensive care is not just a matter of buying a respirator or a blood-gas analyser: the key elements are people who care intensively ". "
SUDDEN UNEXPECTED DEATH SUDDEN death commonly relates to coronary and cerebral vascular disease in the older age-groups, but a report6 from Gainsville, Florida, diverts attention to unexpected death in youth. A 15-year-old boy collapsed and died after a 100-yard sprint. A few hours later his 14-year-old sister fainted and died on hearing of her brother’s death, ventricular fibrillation being recorded. A year earlier another sister had died at age 10 while playing on a beach. In two generations of this family four other instances of sudden unexpected death under the age of 17 years were discovered, with three further cases in their early forties. There was no history of overt heart-disease but, of those dying, eight had had previous episodes of fainting associated with emotion. Post-mortem examination in four children between 6 and 16 years showed no gross abnormality of the heart, but serial sectioning revealed a hypoplastic conduction system in the heart of the boy sprinter and his sister. The atrioventricular node was indistinct and in the boy the right bundle branch had a number of blind-ended ramifications without insertion into the ventricular myocardium. The nodal artery was absent. His sister had a very small right bundle. Sudden death in youth is well recognised in various cardiac anomalies including aortic-valve stenosis, idiopathic hypertrophic suboartic stenosis, and rarer familial conduction disturbances evident in the resting electrocardiogram.7 In the two patients described by Green et al.,6 however, clinical, radiological, and electrocardiographic examinations were normal 2 weeks (the boy) and 1 year (the girl) before death. The degree to which a defective conduction system predisposes to arrhythmias is unknown, and facts are hard to establish. The findings in children with rare conduction anomalies might well be relevant to sudden unexpected death at older ages. Ischsemic degeneration of conduction tissues can lead to deviation of pathways of electrical activation, and this may be associated with electrical instability and arrhythmias 8 under Green, R., Korovetz, M. J., Shanklin, D. R., Devito, J. J., Taylor, W. J. Archs intern. Med. 1969, 124, 359. 7. Jervell, A., Lange-Nielsen, F. Am. Heart J. 1957, 54, 59. 8. Hinkle, L. E., Carver, S. T., Stevens, M. Am. J. Cardiol. 1969, 24, 629.
6.