- Email: [email protected]
STRESS, PROLACTIN, AND INFERTILITY
52 Subcutaneous ancrod is effective in reducing the incidence of total D.V.T. and bilateral D.V.T. in patients with fractured neck of femur treated by the usual method of internal fixation. Furthermore, the reduction in major D.v.T. and bilateral major D.V.T. is still highly statistically significant (P<0.005). Further studies are in progress to determine whether ancrod prophylaxis is effective in patients undergoing hip replacement. G. D. O. LOWE A. F. CAMPBELL D. R. MEEK C. D. FORBES C. R. M. PRENTICE
Royal Infirmary,
Glasgow G4 0SF Health Services Operational Research
Unit,
S. W. CUMMINGS
University of Strathclyde
MYCOBACTERIA CAUSING SEPTIC BURSITIS
SIR,-You state that septic bursitis
can rarely be due to tuberculosis or M.marinum. I and my described two cases of olecranon bursitis attributed to infection with M.szulgai..2 This scotochromic organism, first described in 1972, is readily recognised by thinlayer chromatography of its lipids. It can also cause pulmonary disease and cervical adenitis. It is possible that the organism described as M.marinum by Winter and Runyon in 19653 (not 1975) was in fact M.szulgai. M.szulgai has been shown to be photochromic when grown at 25°C, a key feature in the identification of M.marinum.4
Mycobacterium colleagues have
,
Mycobacterium Reference Unit, Public Health Laboratory Service, University Hospital of Wales, P. A.
Cardiff CF4 4XW.
JENKINS
INTERVAL BETWEEN PREGNANCIES
SIR,-We read with interest your editoriaP on the interval between pregnancies. We believe that the interval between two births is a predictor for certain problems of maternal and child health. However, we have shown that, while short intervals are associated with some adverse pregnancy outcomes, they may not be causal, as seems to be implied by the language of your editorial. We have studied the relation between birth-weight, stillbirth and neonatal death, and interpregnancy interval in a large sample of Norwegian women.We studied nearly 100 000 pairs of siblings. Birth-weight was, on average, lower for those babies who were born after short intervals; the pairmates of these babies were also correspondingly light in weight. Since the length of the interval which succeeds the birth of the earlier-born pair member cannot affect its weight there would seem to be something other than the interval itself that is at the root of the association. Although ample spacing of children may’yield social and cultural advantages, it seems unlikely to us that manipulation of the interpregnancy interval will influence outcomes determined prenatally.
OSTEOLYSIS et al.’ reported a family with hereditary osteolysis, hypertension, and nephropathy. This condi-
SIR,-In 1964, Shurtleff
tion seemed to be inherited as an autosomal dominant with variable expression. Renal disease had only been associated with the "sporadic" form of multiple osteolysis, and had previously never been seen in the familial form of the disease,.23 The evidence for renal disease in the report by Shurtleff et al. was hypertension in three of four affected patients, a unilateral duplication of the renal pelvis and ureter in the fourth, and evidence of arterial and arteriolar sclerosis in the renal biopsy of the father of the proband. Gluck and Miller,4 reporting on another family with hereditary multiple osteolysis, cited a personal communication from Schaller stating that in the 8 years between the two reports, the renal abnormalities in the family described by Shurtleff et al. had resolved. Others have also questioned the validity of the nephropathy reported by Shurtleff et al. We would like to confirm the presence of renal disease in this family. Lately we had the opportunity to re-examine two members of this family, the proband and his father. The proband, 4 years old at the time of the initial report, is now 18, and has undergone a renal transplant for end-stage kidney disease after 9 months on hsemodialysis. Renal biopsies were not done. No specific aetiology for the renal failure was apparent. His father remains hypertensive, but with normal renal function. Erickson et al. have reported a mother and daughter with carpal-tarsal osteolysis. The daughter had 1-2+ proteinuria; the mother had hyaline and granular casts in her urine and 2-4+ proteinuria. They suggested that renal involvement can occur in both the familial and the sporadic forms. We feel that the renal failure in our patient with hereditary multiple osteolysis is unlikely to be fortuitous, but rather reflects an effect of the mutant gene. The absence of nephropathy in most other families with autosomal dominant hereditary multiple osteolysis may reflect a different mutant gene in those kindreds, or variable expression of the same allele (where there would be a real, as yet undefined, risk of progressive nephropathy in individuals who exhibit only bony changes in childhood, as demonstrated by the family reported by Erickson et al. 5) It is also possible that some of the previously reported "sporadic" cases of multiple osteolysis with nephropathy may have been new autosomal dominant mutations. If one of these supposedly sporadic cases were to reproduce, his or her offspring might be at 50% risk of inheriting the condition.
Supported by a fellowship training grant HD 05474 to by grant GM 15253from the National Institutes of Health. Center for Inherited Diseases,
University of Washington, Seattle, Washington 98195, U.S.A.
V.P.S. and
VIRGINIA P. SYBERT ARNO G. MOTULSKY
STRESS, PROLACTIN, AND INFERTILITY SIR,-Might Dr Jeffcoate’s article on hyperprolactinaemia6 a clue to the aetiology of many cases of infertility where organic dysfunction, except perhaps for a raised prolactin, cannot be demonstrated? Jeffcoate states that "there is increasing evidence in man that physical and emotional stress can produce a moderate (rarely a large) increase in prolactin secretion". If even a clinical interview can induce hypersecretion it would seem likely that a prolonged period of stress-for exam-
contain
Bureau of Epidemiology, Center for Disease Control, Atlanta, Georgia 30333, U.S.A.
an
J.
D. ERICKSON
Institute of
Hygiene, University of Oslo, Oslo, Norway
TOR
BJERKEDAL
1. Lancet, 1978, ii, 1135. 2. Marks, J., Jenkins, P. A., Tsukamura, M. Tubercle, 1972, 53, 210. 3. Winter, F. E., Runyon, E. H.J. Bone Jt Surg. 1965, 47A, 375. 4. Schaefer, W. B., Wolinsky, E., Jenkins, P. A., Marks, J. Am. Rev. resp. Dis.
1973, 108, 1320. 5. Lancet. 1978, ii, 879. 6. Erickson, J. D., Bjerkedal, no. 2.
RENAL INVOLVEMENT IN HEREDITARY MULTIPLE
T. J. Epidemiol.
Commun. Hlth, 1978, 32,
1.
D. B., Sparkes, R. S., Clawson, K., Guntheroth, W. G., Mottet, K. J. Am. med. Ass 1964, 188, 363. 2. Thieffry, S., Sorrell-Dejenme, J. Presse med. 1958, 66, 1958. 3. Caffey, J. Pediatric X-ray Diagnosis; p. 984. Chicago, 1961. 4. Gluck, J., Miller, J. J., III. J. Pediat. 1972, 81, 506. 5. Erickson, C. M., Hirschberger, M., Stickler, G. B. ibid. 1978, 93, 779. 6. Jeffcoate, S. L. Lancet, 1978, i, 1245.
Shurtleff, N.
53 an unhappy marriage or when there is a conflict between a woman’s desire to be a mother and to continue with a career-could lead to a sustained increase of the mean prolactin concentration sufficient to cause infertility. Perhaps a psychological or psychiatric assessment of patients in the infertility clinic may provide a way of diagnosing and treating such
ple, during
cases.
Neurosurgical Unit, Royal Infirmary,
P. HAYDN SMITH
Sheffield 6
TOWARDS DEFENSIVE OBSTETRICS to support in the strongest possible terms your editorial and Dr Singer’s letter in your issue of Dec. 23/30 concerning the recent court judgment on handicap thought to have been sustained at birth. Appropriately, you concentrated on the implications of the judgment rather than the clinical details of the case or the justice of making "compensation" available to a handicapped person; these are important, but separate, issues. As you point out, the judgment itself can only help to accelerate a trend towards defensive obstetrics which is already with US.1 In coming to his decision, the judge may have been influenced by widely cited claims that about half of all childhood handicap (usually undefined) could be prevented by adequate care during the perinatal period. In the atmosphere created by such claims, a lay judge may feel that, on balance, he has a 50:50 chance of correctly implicating medical practice in cases of childhood handicap brought before him. Recent statements about the potential for perinatal prevention of childhood handicap have mainly derived from lobbyists outside clinical perinatal practice. Most clinicians seem to have adopted a strategy of tacit acquiescence in these propositions and few have challenged the assumptions on which they rest. In Britain, this position is understandable in the context of central recommendations that expenditure on maternity services should be reduced; but, by default, it may have resulted in the promotion of overoptimistic expectations of the role of perinatal medicine in preventing handicap. If, for example, one starts from an assumption that perinatal practice is everywhere improving, why is it that over the past fifteen years the incidence of cerebral palsy has fallen in Sweden,2risen in Eire,3 and risen then fallen in Australia?4 Our selection of these particular examples reflects the fact that together they represent the best data available on the incidence of just one broad category of handicap. If good descriptive studies are rare, then research identifying setiological mechanisms is even rarer. Simple observation of an association between childhood handicap and adverse signs during the perinatal period remains a wholly inadequate basis for claiming that a high proportion of childhood handicap is preventable by obstetric or paediatric intervention. Although some forms of handicap-have been shown to be preventable by good perinatal care (e.g., the prevention of kernicterus in neonates should eradicate choreoathetosis), the association between other handicaps and perinatal events is far less clear. As Drillien5 points out: "In the absence of other clues one is faced with the ’chicken and egg’ dilemma; is the child profoundly retarded because of hypoxic brain damage which could have been avoided if resuscitative facilities had been available, or did the infant both fail to breathe (after a normal pregnancy and delivery) and present as neurologically abnormal because of existing brain malformation?" The associations become even more blurred when it is acknowledged that deli-
SIR,-We write
Chard, T., Richards, M. P. M. Benefits and Hazards of the New Obstetncs Clins devel. Med. no. 64). London, 1977. 2. Hagberg, B., Hagberg, G., Olow, I. Neuropadiatrie, 1977, 8, suppl. 516. 3 Cussen, G. H., Barry, J. E., Moloney, A. M., Buckley, N. M., Crowley, M., Daly, C.J. Irish med. Ass. 1978, 71, 568. 4. Stanley, F. Paper presented to International Cerebral Palsy Society, in
veries which are considered difficult and traumatic by those involved do not by any means lead inevitably to detectable handicap.6 An analogy can be drawn with ischasmic heart-disease : until recently there was much invested belief that intervention at the time of acute manifestations (infarction) of this chronic disease had great therapeutic potential. We feel therefore that it is essential not only that the Birmingham judgment should be taken to appeal but also that it should highlight the need for further research to elucidate those pathological processes which can be influenced beneficially by intervention during the perinatal period, rather than blindly promoting defensive and over-interventionist perinatal practice. National Perinatal Epidemiology Unit, Research Institute, Churchill Hospital, Oxford OX3 7LJ
IAIN CHALMERS AIDAN MACFARLANE
TRANSŒSOPHAGEAL PULSED DOPPLER ECHOCARDIOGRAPHY
SIR,-Pulsed doppler echocardiography has proven useful for certain cardiac disorders. 1-3 However, because blood-flow is "observed" through a narrow echo window on the chest wall and because the rebounded echoes of blood-cells are very feeble in comparison with those in conventional echocardiography it is very difficult to obtain blood-flow patterns of diagnostic value in adults. To get round this problem, we have developed a system which can obtain the heart blood-flow pattern through the oesophageal wall without hindrance from ribs, sternum, and lung.
Fig. I-Diagram of transcesophageal pulsed doppler system. The system, which was improved from a commercially available pulsed system (A.T.L. pulsed doppler model MHz transducer from the original syshas the small 3 500A), tem,with an outer diameter of 12-5 mm and length 28 mm, installed at the tip of.a flexible shaft. A round metal mirror is fixed near the transducer face plate to emit ultrasound beam in the direction of the heart (fig. 1). The mirror and the transducer are covered by an oil bag, which can be filled with oil by means of an injector. The ultrasound beam emitted from the transducer face is reflected at a right angle by the metal mirror. A strip-chart recorder is used for display method, and an online, real-time, graphic display of the doppler shift frequencies is printed on it.44 The system has been evaluated in seven adults. They swallowed about 3 g of lignocaine jelly and then their throats were sprayed with 4% lignocaine after which the transducer and the oil bag could be swallowed as easily as a gastrofiberscope. Gagging apart, no serious complications were encountered. In all subjects, stable flow patterns of good quality in both ventricles, both atria, and aorta were obtained (fig. 2). In the transoesophageal method, blood-flow patterns are
doppler
observed through the thin oesophageal wall in which ultrasound absorption is very low. Therefore, stable and high qua-
1.
6. Brown, 1. 2.
Aosta, 1978. 5. Drillien, D.
in Major Mental Handicap: methods Ciba Fnd Symp. 59; p. 19. London, 1978.
and
costs
of prevention
3. 4.
J. K. in Recent Advances in Pædiatrics no. 5 (edited by D. Hull); p. 35. Edinburgh, 1976. Wells, P. N. T. Med. Biol. Eng. 1969, 7, 641. Gould, K. L., Mozersky, K. J., Hokanson, K. E., Baker, D. W., Kennedy, J W. Sumner, D. S., Strandness, D. E., Jr. Circulation, 1972, 46, 595. Stevenson, J C , Kawabori, I., Guntheroth, W. G. ibid. 1977, 56, 14. Baker, D. W., Rubenstein, S. A., Lorch, G. S. Am. J. Med. 1977, 63, 69.
Royal Infirmary,
Glasgow G4 0SF Health Services Operational Research
Unit,
S. W. CUMMINGS
University of Strathclyde
MYCOBACTERIA CAUSING SEPTIC BURSITIS
SIR,-You state that septic bursitis
can rarely be due to tuberculosis or M.marinum. I and my described two cases of olecranon bursitis attributed to infection with M.szulgai..2 This scotochromic organism, first described in 1972, is readily recognised by thinlayer chromatography of its lipids. It can also cause pulmonary disease and cervical adenitis. It is possible that the organism described as M.marinum by Winter and Runyon in 19653 (not 1975) was in fact M.szulgai. M.szulgai has been shown to be photochromic when grown at 25°C, a key feature in the identification of M.marinum.4
Mycobacterium colleagues have
,
Mycobacterium Reference Unit, Public Health Laboratory Service, University Hospital of Wales, P. A.
Cardiff CF4 4XW.
JENKINS
INTERVAL BETWEEN PREGNANCIES
SIR,-We read with interest your editoriaP on the interval between pregnancies. We believe that the interval between two births is a predictor for certain problems of maternal and child health. However, we have shown that, while short intervals are associated with some adverse pregnancy outcomes, they may not be causal, as seems to be implied by the language of your editorial. We have studied the relation between birth-weight, stillbirth and neonatal death, and interpregnancy interval in a large sample of Norwegian women.We studied nearly 100 000 pairs of siblings. Birth-weight was, on average, lower for those babies who were born after short intervals; the pairmates of these babies were also correspondingly light in weight. Since the length of the interval which succeeds the birth of the earlier-born pair member cannot affect its weight there would seem to be something other than the interval itself that is at the root of the association. Although ample spacing of children may’yield social and cultural advantages, it seems unlikely to us that manipulation of the interpregnancy interval will influence outcomes determined prenatally.
OSTEOLYSIS et al.’ reported a family with hereditary osteolysis, hypertension, and nephropathy. This condi-
SIR,-In 1964, Shurtleff
tion seemed to be inherited as an autosomal dominant with variable expression. Renal disease had only been associated with the "sporadic" form of multiple osteolysis, and had previously never been seen in the familial form of the disease,.23 The evidence for renal disease in the report by Shurtleff et al. was hypertension in three of four affected patients, a unilateral duplication of the renal pelvis and ureter in the fourth, and evidence of arterial and arteriolar sclerosis in the renal biopsy of the father of the proband. Gluck and Miller,4 reporting on another family with hereditary multiple osteolysis, cited a personal communication from Schaller stating that in the 8 years between the two reports, the renal abnormalities in the family described by Shurtleff et al. had resolved. Others have also questioned the validity of the nephropathy reported by Shurtleff et al. We would like to confirm the presence of renal disease in this family. Lately we had the opportunity to re-examine two members of this family, the proband and his father. The proband, 4 years old at the time of the initial report, is now 18, and has undergone a renal transplant for end-stage kidney disease after 9 months on hsemodialysis. Renal biopsies were not done. No specific aetiology for the renal failure was apparent. His father remains hypertensive, but with normal renal function. Erickson et al. have reported a mother and daughter with carpal-tarsal osteolysis. The daughter had 1-2+ proteinuria; the mother had hyaline and granular casts in her urine and 2-4+ proteinuria. They suggested that renal involvement can occur in both the familial and the sporadic forms. We feel that the renal failure in our patient with hereditary multiple osteolysis is unlikely to be fortuitous, but rather reflects an effect of the mutant gene. The absence of nephropathy in most other families with autosomal dominant hereditary multiple osteolysis may reflect a different mutant gene in those kindreds, or variable expression of the same allele (where there would be a real, as yet undefined, risk of progressive nephropathy in individuals who exhibit only bony changes in childhood, as demonstrated by the family reported by Erickson et al. 5) It is also possible that some of the previously reported "sporadic" cases of multiple osteolysis with nephropathy may have been new autosomal dominant mutations. If one of these supposedly sporadic cases were to reproduce, his or her offspring might be at 50% risk of inheriting the condition.
Supported by a fellowship training grant HD 05474 to by grant GM 15253from the National Institutes of Health. Center for Inherited Diseases,
University of Washington, Seattle, Washington 98195, U.S.A.
V.P.S. and
VIRGINIA P. SYBERT ARNO G. MOTULSKY
STRESS, PROLACTIN, AND INFERTILITY SIR,-Might Dr Jeffcoate’s article on hyperprolactinaemia6 a clue to the aetiology of many cases of infertility where organic dysfunction, except perhaps for a raised prolactin, cannot be demonstrated? Jeffcoate states that "there is increasing evidence in man that physical and emotional stress can produce a moderate (rarely a large) increase in prolactin secretion". If even a clinical interview can induce hypersecretion it would seem likely that a prolonged period of stress-for exam-
contain
Bureau of Epidemiology, Center for Disease Control, Atlanta, Georgia 30333, U.S.A.
an
J.
D. ERICKSON
Institute of
Hygiene, University of Oslo, Oslo, Norway
TOR
BJERKEDAL
1. Lancet, 1978, ii, 1135. 2. Marks, J., Jenkins, P. A., Tsukamura, M. Tubercle, 1972, 53, 210. 3. Winter, F. E., Runyon, E. H.J. Bone Jt Surg. 1965, 47A, 375. 4. Schaefer, W. B., Wolinsky, E., Jenkins, P. A., Marks, J. Am. Rev. resp. Dis.
1973, 108, 1320. 5. Lancet. 1978, ii, 879. 6. Erickson, J. D., Bjerkedal, no. 2.
RENAL INVOLVEMENT IN HEREDITARY MULTIPLE
T. J. Epidemiol.
Commun. Hlth, 1978, 32,
1.
D. B., Sparkes, R. S., Clawson, K., Guntheroth, W. G., Mottet, K. J. Am. med. Ass 1964, 188, 363. 2. Thieffry, S., Sorrell-Dejenme, J. Presse med. 1958, 66, 1958. 3. Caffey, J. Pediatric X-ray Diagnosis; p. 984. Chicago, 1961. 4. Gluck, J., Miller, J. J., III. J. Pediat. 1972, 81, 506. 5. Erickson, C. M., Hirschberger, M., Stickler, G. B. ibid. 1978, 93, 779. 6. Jeffcoate, S. L. Lancet, 1978, i, 1245.
Shurtleff, N.
53 an unhappy marriage or when there is a conflict between a woman’s desire to be a mother and to continue with a career-could lead to a sustained increase of the mean prolactin concentration sufficient to cause infertility. Perhaps a psychological or psychiatric assessment of patients in the infertility clinic may provide a way of diagnosing and treating such
ple, during
cases.
Neurosurgical Unit, Royal Infirmary,
P. HAYDN SMITH
Sheffield 6
TOWARDS DEFENSIVE OBSTETRICS to support in the strongest possible terms your editorial and Dr Singer’s letter in your issue of Dec. 23/30 concerning the recent court judgment on handicap thought to have been sustained at birth. Appropriately, you concentrated on the implications of the judgment rather than the clinical details of the case or the justice of making "compensation" available to a handicapped person; these are important, but separate, issues. As you point out, the judgment itself can only help to accelerate a trend towards defensive obstetrics which is already with US.1 In coming to his decision, the judge may have been influenced by widely cited claims that about half of all childhood handicap (usually undefined) could be prevented by adequate care during the perinatal period. In the atmosphere created by such claims, a lay judge may feel that, on balance, he has a 50:50 chance of correctly implicating medical practice in cases of childhood handicap brought before him. Recent statements about the potential for perinatal prevention of childhood handicap have mainly derived from lobbyists outside clinical perinatal practice. Most clinicians seem to have adopted a strategy of tacit acquiescence in these propositions and few have challenged the assumptions on which they rest. In Britain, this position is understandable in the context of central recommendations that expenditure on maternity services should be reduced; but, by default, it may have resulted in the promotion of overoptimistic expectations of the role of perinatal medicine in preventing handicap. If, for example, one starts from an assumption that perinatal practice is everywhere improving, why is it that over the past fifteen years the incidence of cerebral palsy has fallen in Sweden,2risen in Eire,3 and risen then fallen in Australia?4 Our selection of these particular examples reflects the fact that together they represent the best data available on the incidence of just one broad category of handicap. If good descriptive studies are rare, then research identifying setiological mechanisms is even rarer. Simple observation of an association between childhood handicap and adverse signs during the perinatal period remains a wholly inadequate basis for claiming that a high proportion of childhood handicap is preventable by obstetric or paediatric intervention. Although some forms of handicap-have been shown to be preventable by good perinatal care (e.g., the prevention of kernicterus in neonates should eradicate choreoathetosis), the association between other handicaps and perinatal events is far less clear. As Drillien5 points out: "In the absence of other clues one is faced with the ’chicken and egg’ dilemma; is the child profoundly retarded because of hypoxic brain damage which could have been avoided if resuscitative facilities had been available, or did the infant both fail to breathe (after a normal pregnancy and delivery) and present as neurologically abnormal because of existing brain malformation?" The associations become even more blurred when it is acknowledged that deli-
SIR,-We write
Chard, T., Richards, M. P. M. Benefits and Hazards of the New Obstetncs Clins devel. Med. no. 64). London, 1977. 2. Hagberg, B., Hagberg, G., Olow, I. Neuropadiatrie, 1977, 8, suppl. 516. 3 Cussen, G. H., Barry, J. E., Moloney, A. M., Buckley, N. M., Crowley, M., Daly, C.J. Irish med. Ass. 1978, 71, 568. 4. Stanley, F. Paper presented to International Cerebral Palsy Society, in
veries which are considered difficult and traumatic by those involved do not by any means lead inevitably to detectable handicap.6 An analogy can be drawn with ischasmic heart-disease : until recently there was much invested belief that intervention at the time of acute manifestations (infarction) of this chronic disease had great therapeutic potential. We feel therefore that it is essential not only that the Birmingham judgment should be taken to appeal but also that it should highlight the need for further research to elucidate those pathological processes which can be influenced beneficially by intervention during the perinatal period, rather than blindly promoting defensive and over-interventionist perinatal practice. National Perinatal Epidemiology Unit, Research Institute, Churchill Hospital, Oxford OX3 7LJ
IAIN CHALMERS AIDAN MACFARLANE
TRANSŒSOPHAGEAL PULSED DOPPLER ECHOCARDIOGRAPHY
SIR,-Pulsed doppler echocardiography has proven useful for certain cardiac disorders. 1-3 However, because blood-flow is "observed" through a narrow echo window on the chest wall and because the rebounded echoes of blood-cells are very feeble in comparison with those in conventional echocardiography it is very difficult to obtain blood-flow patterns of diagnostic value in adults. To get round this problem, we have developed a system which can obtain the heart blood-flow pattern through the oesophageal wall without hindrance from ribs, sternum, and lung.
Fig. I-Diagram of transcesophageal pulsed doppler system. The system, which was improved from a commercially available pulsed system (A.T.L. pulsed doppler model MHz transducer from the original syshas the small 3 500A), tem,with an outer diameter of 12-5 mm and length 28 mm, installed at the tip of.a flexible shaft. A round metal mirror is fixed near the transducer face plate to emit ultrasound beam in the direction of the heart (fig. 1). The mirror and the transducer are covered by an oil bag, which can be filled with oil by means of an injector. The ultrasound beam emitted from the transducer face is reflected at a right angle by the metal mirror. A strip-chart recorder is used for display method, and an online, real-time, graphic display of the doppler shift frequencies is printed on it.44 The system has been evaluated in seven adults. They swallowed about 3 g of lignocaine jelly and then their throats were sprayed with 4% lignocaine after which the transducer and the oil bag could be swallowed as easily as a gastrofiberscope. Gagging apart, no serious complications were encountered. In all subjects, stable flow patterns of good quality in both ventricles, both atria, and aorta were obtained (fig. 2). In the transoesophageal method, blood-flow patterns are
doppler
observed through the thin oesophageal wall in which ultrasound absorption is very low. Therefore, stable and high qua-
1.
6. Brown, 1. 2.
Aosta, 1978. 5. Drillien, D.
in Major Mental Handicap: methods Ciba Fnd Symp. 59; p. 19. London, 1978.
and
costs
of prevention
3. 4.
J. K. in Recent Advances in Pædiatrics no. 5 (edited by D. Hull); p. 35. Edinburgh, 1976. Wells, P. N. T. Med. Biol. Eng. 1969, 7, 641. Gould, K. L., Mozersky, K. J., Hokanson, K. E., Baker, D. W., Kennedy, J W. Sumner, D. S., Strandness, D. E., Jr. Circulation, 1972, 46, 595. Stevenson, J C , Kawabori, I., Guntheroth, W. G. ibid. 1977, 56, 14. Baker, D. W., Rubenstein, S. A., Lorch, G. S. Am. J. Med. 1977, 63, 69.