REVERSIBLE DEATH

188 and his co-workershave lately rewith a persistent growth of introital enterobacteria had the most episodes OfU.T.I. during followup. A single bacterial count in excess of 100,000 per ml. in patients known to have their introital areas heavily contaminated with enterobacteria is unlikely to have the same significance as in the general female population. At least in research situations, the diagnosis of u.T.i. must be made with absolute confidence. No worker will accept the simplicity and obvious advantages of S.P.A. until he has used it. I believe it satisfies the need expressed in your editorial (Jan. 9, p. 71) for a test which will distinguish significant from non-significant bacteriuria.

Professor

ported that

O’Grady women

Renal Infection Unit, Charing Cross Hospital Medical School, Fulham Hospital,

London W.6.

SIR,-In their

paper (Jan. 2, p. 9), Dr. Lawson and Dr. Miller conclude that the benefits derived from the screening of patients for bacteriuria do not justify the effort involved in its performance. Unfortunately, they do not say precisely what bacteriological method was used, and it is impossible therefore satisfactorily to evaluate their very important findings. The routine screening of urine for significant bacteriuria can be laborious and time-consuming if this depends on the performance of a viable count. Chemical tests are not entirely satisfactory, in that certain bacteria encountered in urinary-tract infec-

tions

most

interesting

very inactive

biochemically. Currently we are exploring possibility of counting bacteria in urine by a relatively simple and quick instrumented method. are

the

Central Middlesex Hospital, London N.W.10.

Anencephalic child with

Ross R. BAILEY.

extra

leg.

developed as far as the hair-line, but there the skull stopped abruptly and the poorly developed brain, covered by meninges, protruded in a cauliflower manner. The mother was aged 17, a primipara, and a native of Jobore (six miles from Ijebu-Ode). She had her antenatal supervision at the Rural Health Centre, Ketu. When first seen there (in the first trimester) she had admitted to using a native medicine commonly taken by pregnant women

in this part of the Federation. She had

not

been ill

during this period. At the Rural Health Centre she had been given the usual antenatal drugs-ferrous sulphate, vitamin C, and folic acid. State Hospital, Ijebu-Ode, Nigeria.

A.

OKUBOYEJO.

C. E. D. TAYLOR M. A. T. COLES. REVERSIBLE DEATH

UNRECOGNISED EPIDEMIC OF ANENCEPHALY AND SPINA BIFIDA

SiR,-The interesting report by Professor MacMahon and Dr. Yen (Jan. 2, p. 31) refers to the distribution of births of babies with anencephaly and spina bifida in time, but not on a geographical basis. I think it would be of value if it were possible to ascertain the addresses of the mothers concerned at the time of conception, especially during the epidemic period. If these were plotted on a map, they might throw some light on the epidemiology of the condition. Ideally, it is not sufficient merely to register congenital abnormalities as we do in this country: each pregnancy could be investigated quite simply with an inquiry into locality at time of conception and early gestation. After all, detailed inquiries are made of personal movements and activities in outbreaks of infectious disease in attempts to ascertain the causes; and one cannot help wondering why they are not undertaken for more serious conditions, such as congenital abnormalities. Health Department, Oxford.

M. J. PLEYDELL.

EXTRA LEG WITH ANENCEPHALY

SIR,-We wish to report the delivery of a three-legged child at the State Hospital, Ijebu-Ode. The child, a male, was alive but blue at birth, and weighed 8 lb. 2 oz. He had two normal legs 8 inches long, and a third arising from the back just above the cleft of the buttocks. The third leg was 2 inches shorter than the others and had only two The face was normally toes (see accompanying figure). 8.

O’Grady, F. W., Richards, B., McSherry, M. A., O’Farrell, S. M., Cattell, W. R. Lancet, 1970, ii, 1208.

SIR,-Your editorial with this titlerightly draws attention to the fact that a flat E.E.G. (the term isoelectric E.E.G. is preferable) may be found during some forms of coma, and that it does not preclude complete recovery. It is unfortunate that the title of the editorial might be taken to mean that the isoelectric E.E.G. is synonymous with death. This is certainly not the case, and, apart from those conditions that you mention (severe brainstem damage from compressive or non-compressive cerebral lesions, hepatic coma, and hypoglycxmia), there are many, such as drug overdose2 and encephalitis,3 which may also be reversible despite an isoelectric E.E.G. These conditions, however, are all rather uncommon and an isoelectric E.E.G. unquestionably carries a severe prognosis. Indeed, a review was carried out under the xgis of the American E.E.G. Society4 concerning 2000 patients with isoelectric E.E.G.s from a variety of causes: there were only 3 survivors, all of whom had had drug overdoses. In our experience, most of the patients in whom this type of E.E.G. is recorded have had acute cerebral anoxia, and are quite different from those of Brendler and Selverstone5 in that spontaneous respiratory movements have ceased and other spontaneous reflex functions, all necessary features for the determination of death,6 are absent. Prognosis in this group can reliably be predicted from the E.E.G.7 The isoelectric E.E.G. has become particularly important 1.

2. 3.

Lancet, 1970, ii, 1172. Bird, T. D., Plum, F. Neurology, 1968, 18, 456. Bental, E., Leibowitz, U. Electroenceph. clin. Neurophysiol. 1961.

13, 457. Silverman, D., Saunders, M. D., Schwab, R. S., Masland, R. L. J. Am. med. Ass. 1969, 209, 1505. 5. Brendler, S. J., Selverstone, B. Brain, 1970, 93, 381. 6. Harvard Committee, J. Am. med. Ass. 1969, 205, 337. 7. Binnie, C. D., Prior, P. F., Lloyd, D. S. L., Scott, D. F., Margerison, J. H. Br. med. J. 1970, iv, 265.

4.

189 since donors have been needed for organ

transplants.

authorities-for example, Juul-Jenson 8-regard patients with certain forms of coma associated with neurosurgical conditions and isoelectric E.E.G.s as suitable donors, and indeed exclude those with severe anoxic brain damage. We feel it is of the utmost importance that an isoelectric E.E.G. should be recorded, under satisfactory technical conditions,’ and this should be assessed in conjunction with all the information available to the clinician. Particular attention should be paid to those special types of reversible condition referred to above which may lead to an isoelectric Some

E.E.G.

E.E.G. Department, London Hospital, E.1.

D. F. SCOTT PAMELA F. PRIOR.

MEDICAL EDUCATION AND MEDICAL RESEARCH

SIR,-It is always a pleasure to read the stimulating words of the Vice-Chancellor of Newcastle University (Jan. 2, p. 1), but I feel that he at least owes it to the dignity of his position in the academic hierarchy that he should endeavour, when riding his hobby-horse, to make certain that his facts are correct. In referring to the special institutes within the University of London, he complains about a situation which may indeed have existed thirty to forty years ago, and which may well have been appropriate then, without apparently realising that his points of criticism had been appreciated by the institutes themselves, and that the steps he suggests should be taken are now a matter of history. At the Institute of Neurology, a special target of his criticism, there are, in all, 27 staff members of consultant status in neurology, neurosurgery, and neurophysiology, including National Health and University appointments. Of these, 4 neurologists are geographically full-time at the Institute hospitals, with minor commitments, either clinical or research, that they have chosen to assume at other conveniently near institutions because of their special interests; and a 5th has a nominal session at a teaching hospital. 1 neurosurgeon is geographically full-time, 1 other has a lesser consulting commitment only at another nearby undergraduate hospital. A 3rd neurosurgeon is being replaced by a maximum full-time appointment jointly with the hospital next door in Great Ormond Street. 5 physiologists out of 6 are geographically full-time. 4 further neurologists have research laboratories with foundation-supported research programmes that result in their major commitment being within the Institute or hospital buildings, although they have other clinical responsibilities elsewhere. This is hardly a matter of a few hours a week at the Institute ". It will be noted that the above remarks Of the consulting cover more than half the clinical staff. staff, only 3 have consulting-rooms in Harley Street; 2 consult in their own homes, and the rest of those who have a private practice carry it out in consulting-rooms in the hospital buildings. All the special departments not mentioned are, of course, almost entirely staffed by full-time university or hospital appointments. There are 5 senior registrars, 12 registrars, and many more lecturers and research fellows all working full-time within the Institute and hospitals, some on clinically oriented research, others in basic research, others mainly in the clinical field-but even these are finishing in their off-duty time research programmes started before they commenced their training appointments in clinical neurology. One has only to look, for example, at the contribution made by the department of neurology in the university of which Dr. Miller is the vice-chancellor to realise the diffi"

8. Juul-Jenson, P. Criteria of Brain Death. 9. Poole, E. Br. med. J. 1970, iii, 346.

Copenhagen,

1970.

culties that are likely to be met by departments of neurology in undergraduate teaching hospitals which wish to build up a clinical and research effort such as is concentrated at the Institute of Neurology. Even a forward-looking university like Newcastle, and in a department of neurology whose contributions are recognised and admired by all, the university contribution is very small. It is less still in other universities, and attempts to encourage this sort of effort are regarded as being likely to produce an unwieldy lack of balance between neurology and the other departments, and such growth has tended to be stifled on account of this fear. Finally, Dr. Miller has a constant anxiety about the time that those of us who work in London spend in cars. Even though it is a comparatively minor point, he is misinformed. " Speaking as one of the " general practitioners of the specialty, I can assure him that, although I have commitments at both hospitals of the Institute and an undergraduate teaching hospital, I rarely spend a total of more than thirty minutes a day in my car. The car usually does move throughout that thirty minutes, an average time that I feel is probably no more than is spent by many geographically full-time clinicians working in other hospitals and colleges in other urban areas. Institute of Neurology, REGINALD KELLY, National Hospital, London W.C.1.

Dean.

LYMPHOCYTE SENSITISATION IN CANCER

SIR,-Because space for our preliminary communicationwas limited, we did not comment on some of the points raised by Dr. Weir (Jan. 9, p. 80). In addition to nervous and muscle antigens we have used bovine-serumalbumen, egg-albumen, Kveim reagent, and P.P.D. to study patients with cancer, sarcoidosis, and lupus as well as normal controls. Apart from the patients with structural changes in the nervous system, none save those with malignant neoplasia showed exclusive sensitisation to encephalitogenic factor (E.F.) and sciatic-nerve basic protein (B.P.). In sarcoidosis and lupus, on the other hand, there was sensitisation to all antigens tested, and this was true also of a small number of "non-B.c.G. converters " and Crohn’s disease patients but not of cancer patients (results to be published). In addition to the controls listed in tables 11 and III we have tested patients with high E.S.R. consequent upon pneumonia, extensive trauma from accidents, or joint surgery, and have not found that E.F. or any other antigen gives a raised result. On the other hand, sensitisation to E.F. seems to persist for many years in apparently healthy patients after cancer has been successfully treated, and to be present in early cases without known chronic infection. Patient no. 11 in table 11 had been in a chronic infective state for years, and patient no. 2 for some months, but neither gave a positive result. There is one important exception. In 1963, we reported that B.c.G. inoculation of young people produces circulating antibody to E.F. and suggested that E.F. might share antigenic determinant(s) with tubercle bacillus.2 We have therefore tested four patients with severe active pulmonary tuberculosis and found high sensitisation to E.F. as well as P.P.D. and lesser degrees of sensitisation to B.P., confirming our previous suggestion. These tuberculous patients do not, however, show high sensitisation to other antigens. Experiments have also been carried out to test the blocking activity of serotonin on the lymphocyte/E.F. interaction, following the important suggestion by Carnegie3 that the material was a good fit " to E.F. Whilst serotonin blocks E.F. completely, it blocks B.P. less and P.P.D. still less, and "

1. 2. 3.

Field, E. J., Caspary, E. A. Lancet, 1970, ii, 1337. Field, E. J., Caspary, E. A., Ball, E. J. ibid. 1963, ii, 11. Carnegie, P. R. Nature, 1971, 229, 25.