- Email: [email protected]
THE SOCIAL FATE OF THE AMPUTEE
1315
conduction at this period may be unstable. I would suggest that a dive reflex could trigger a fatal outcome. To prove the hypothesis in any of the three contingencies described above, one would need to demonstrate the presence of saliva in the larynx or about the nares at necropsy and to show that this had been present at the time of death. This point could be difficult to establish. 12 Collins Street, Melbourne 3000, Australia.
diagnogir
KATE CAMPBELL.
PRECAPILLARY BYPASS AND SUDDEN INFANT DEATH SiR,-The syndrome of sudden unexpected death in infancy is still unexplained. I wish to put forward a hypothesis based on the resemblances between the lung picture in this syndrome and that in the respiratory-distress
syndrome of neonates. In the respiratory-distress syndrome the right-to-left shunt largely takes place in the lungs and 2 necropsy may reveal a patent precapillary bypass. It seems possible that this bypass could reopen sufficiently to cause anoxaemia. This possibility led me to investigate the lungs of a male infant aged 8 months who died unexpectedly in an orphanage. No signs of disease had been noted previously, and the necropsy diagnosis was suffocation. I injected indian ink into the pulmonary artery of one excised lung. (In a normal lung the ink enters easily, and the lung becomes black.) No ink was seen to enter macroscopically, and histological sections showed no ink in the capillaries; there was, however, ink in the precapillary bypasses. The precapillary bypass is formed by bronchial/pulmonary artery anastomoses and arteriovenous anastomo-
ses.3,4 I suggest that a change in vagal tone could trigger the reopening of the bypass. This would be impossible in older children, in whom the bypass is obliterated. Changes in vagal tone could be precipitated by mechanisms such as upper-respiratory-tract infection. Department of Pædiatrics, University of Turku 205 20, Turku 50, Finland.
S. JÄYKKÄ.
SUDDEN DEATHS IN INFANTS
SiR,-Your leader of Nov. 13 asks whether sudden deaths in infants take place in hospital. I have personally seen four cases. Two were in the infants’ ward, one in the special-care unit, and one on the normal newborn service. I believe that other paediatricians have had the same experience. Welsh National School of Medicine, Department of Child Health,
Llandough Hospital, Penarth, Glam. CF6 1XX.
O. P. GRAY.
ASPIRIN-INDUCED HYPOGLYCÆMIA IN A PATIENT ON HÆMODIALYSIS SIR,-We were interested to read the letter by Dr. David and others (Nov. 13, p. 1092). We have drawn attention to the occurrence of spontaneous hypoglycsemia in diabetic patients with renal failure.ó Since only a fasting blood-sugar was measured in their patient (90 mg. per 100 ml.), the possibility of underlying diabetes mellitus does not seem to have been unequivocally excluded.In 1. 2. 3. 4. 5. 6.
Murdock,
this regard, the findings on renal biopsy would be instructive, for the nature of the patient’s kidney disease is not clear from the case-report. Although aspirin may well have been involved in producing hypoglycsmia, alternative possibilities should be considered. However, in the absence of plasma salicylate and insulin determinations it is unlikely that a definitive
A. I., Kidd, B. S. L., Llewellyn, M. A., McReid, M., Swyer, P. R. Biol. Neonat. 1970, 15, 1. Jäykkä, S. P. O. Acta pœdiat. 1958, 47, 484. von Hayek, H. Die menschliche Lunge. Berlin, 1953. Lauweryns, J. De Longvaten. Arscia uitgaven. Brussels, 1962. Block, M. B., Rubenstein, A. H. J. Am. med. Ass. 1970, 213, 1863. Block, M. B., Mako, M., Rubenstein, A. H. Clin. Res. 1971, 14, 685.
can
he marie.
University of Chicago, Department of Medicine, 950 East 59th Street, Chicago, Illinois 60637.
MARSHALL B. BLOCK ARTHUR H. RUBENSTEIN.
CROMOGLYCATE IN ALLERGIC RHINITIS SIR,—Your annotation (Dec. 4, p. 1243) prompts me todescribe a simple method of assessing this drug in allergic rhinitis. This condition is notoriously variable in severity,. and if the drug is tried during a good phase the patient will conclude that it works. I have found it useful to tell the patient to use it four times daily, in one nostril only, for one week. Results are usually clearcut. General adoption of this method could save the N.H.S. a great deal of money, 110 Old Park Ridings, Winchmore Hill, London N.21
I. S. MUIR.
THE SOCIAL FATE OF THE AMPUTEE
SIR,—Mr. Chilvers and Mr. Browse (Nov. 27, p. 1192) record that 11 out of 20 patients who had a unilateral. amputation for ischaemic disease at an elderly age were faced with the double trauma of an amputation and gross disturbance of their environment. 7 of them were admitted to institutions, and while they were waiting they occupied an acute surgical bed for many weeks. It is not generally recognised that a large number of elderly patients are subjected to amputation-more than 3000 a year are treatedby the limb-fitting service. We have therefore made a special study of this problem at Queen Mary’s Hospital, Roehampton, because we feel that the best solution is to return these patients capable of an independent existence to their own homes after the amputation. To this end we have adopted a policy of below-knee amputation wherever possible, and 82% of the amputations performed in our unit are at below-knee level, with a result that in the past four years 39 patients have been returned to their own homes capable of independent existence, many of them in fact living on their own. Only 2 patients who previously lived in their own homes were transferred to geriatric units, and 6 patients, who were in an institution before their amputation, were returned to an institution. The average age of the patients treated at Queen Mary’s Hospital has been 72 years, with the eldest 95 years. To obtain this high proportion of rehabilitated patients we have accepted the necessity that these patients should be retained in hospital until they are capable of an independent existence. This has led to some of these
patients remaining in hospital for as long as six months, but the majority are discharged in a much shorter time and when these patients have been reviewed at home, in, a course of a survey which we are undertaking, it is apparent that it was well worth returning them to their normal existence whenever possible. It is apparent to us that if elderly patients who have had an amputation are not to be relegated to institutional care, facilities must be made available for hospital rehabilitation before they return home. A close cooperation between hospital, general practitioner, social worker, and patient, which is best achieved by a home visit before the patient leaves hospital, and the provision of pylons and prostheses by the limb-fitting service with a minimum of delay, are
1316
important. The cooperation of the patient’s relatives is more likely to be secured when they realise the patient will retain some independence and will not be a total burden on the household. By placing the emphasis on all these factors, we believe the need for geriatric care of these patients can be reduced to a minimum and the quality of their survival can be thereby improved. Queen Mary’s Hospital, Roehampton, London SW15 5PN.
K. P. ROBINSON.
IS SELENIUM A TERATOGEN ?
SIR,-Robertson1 has suggested that selenium might teratogenic in two groups of female workers who weighed out selenite-containing powder-an ingredient have been
in a medium for salmonella culture. Robertson’s observation is consistent with that of Moxon and Rhian 2 who reported that affected chickens in high seleniferous regions have eggs which are either sterile or produce a high percentage of monstrosities. Hadjimarkos3 observed that children who were lifelong residents of the high-selenium areas of Oregon, Wyoming, Montana, and South Dakota have a greater than average susceptibility to dental caries. On the other hand, Holmberg and Ferm 4 reported that sodium selenite, under certain conditions, actually protects hamsters against the teratogenic effects of cadmium and arsenic. Because of the possibility that selenium might also be a teratogen at physiological levels, a study was undertaken to see whether there is a relationship between selenium concentration in the environment and neonatal deaths. High, medium, and low selenium Statesand their respective neonatal death-rates are listed in the figure. The District of Columbia was included in the low-selenium group. Allaway et al.have shown higher blood-selenium in normal people in high-selenium areas and lower bloodselenium in people from low-selenium areas. Populations of these States were found in the 1960 census and neonatal deaths were found in Vital Statistics.1 Neonatal deaths were chosen, since this statistic is most likely to reflect any teratogenic effect. 1. Robertson, D. S. F. Lancet, 1970, i, 518. 2. Moxon, A. L., Rhian, M. Physiol. Rev. 1943, 23, 305. 3. Hadjimarkos, D. M. Lancet, 1970, i, 721. 4. Holmberg, R. E., Ferm, V. H. Archs envir. Hlth, 1969, 18, 6. 5. Kubota, J., Allaway, W. H., Carter, D. L., Cary, E. E., Lazar, V. A. J. agr. Fd Chem. 1967, 15, 448. 6. Allaway, W. H., Kubota, J., Losee, F., Roth, M. Archs envir. Hlth, 1968, 16, 342. 7. Vital Statistics of the United States; Vol. II, part B. United States Department of H.E.W., Public Health Service, National Vital Statistics Division, Washington, 1960.
The high, medium, and low selenium States had average neonatal death-rates and standard errors of 720 ±34-6, 760±24, and 927 28. The differences between the high and medium selenium States and the low-selenium States are highly significant using Student’s t test (P< 0-001). Selenium is an essential trace element necessary for the growth and development of quail, rats, and chickens.a Selenium is probably an essential trace element for human beings as well.9 At physiological levels such as those found in the United States environment, selenium may also be necessary for the proper growth and development of the human embryo. No enhancement of teratogenicity was seen. The inverse relationship found here between neonatal deaths and selenium at physiological levels, and the known teratogenicity of selenium at toxic levels in animals,2 draws an interesting parallel to the inverse relationship reported between selenium occurrence and human cancer mortality.8 At nutritional levels, dietary selenium prevented tumour formation in animals,lO but at dosages approaching chronic poisoning for three years selenium may increase the spontaneous tumours that occur in old rats.9 Division of Laboratory Medicine, Department of Biochemistry, Cleveland Clinic Foundation, Cleveland, Ohio 44106, U.S.A.
RAYMOND
J. SHAMBERGER.
ENTEROCOLITIS FOLLOWING EXCHANGE TRANSFUSION SIR,-In reply to Dr. Super’s letter (Nov. 27, p. 1203), I agree that it is likely that several factors are involved in the complication ileocolitis following exchange transfusion. In 2 of the cases that have occurred in this region sodium bicarbonate 8-5% was not injected into the umbilical vein. The Department of Health is investigating any possible hazards associated with the use of the heating coil, and until it has been passed by them I have discontinued its use. Alder Hey Children’s Eaton
Hospital,
Road,
A. E. MCCANDLESS.
Liverpool L12 2AP.
JUST A MACHINE ? SIR,-Dr. Habershon (Dec. 4, p. 1257) asks this question and states that " it is one of the most important questions for discussion today ". We are not just machines, since the most sophisticated machines that we have developed are simple and crude by comparison with our IS MAN
bodies. The fact that we have learnt so much about ourselves and the universe in the last few moments of our evolution is due to the emergence of disciplined thought that requires that the words and concepts that we use be agreeably defined. When we apply this disciplined thought to the hypothesis that we can be other than we are-i.e., that we have free-will -we find that the evidence, which is very extensive, is entirely against it. Many of us, in the present and previous centuries, who have come to the conclusion that free-will is an illusion have been afraid to accept and broadcast the fact for fear that it might rob life of some of its most precious things and Shamberger, R. J., Willis, C. E. Crit. Rev. clin. Chem. 1971, 2, 211. 9. Schroeder, H. A., Frost, D. V., Balassa, J. J.J. chron. Dis. 1970 23, 227. 10. Shamberger, R. J. J. natn. Cancer Inst. 1970, 44, 931. 8.
Selenium levels in different States, in relation to neonatal death-rate, 1960.
conduction at this period may be unstable. I would suggest that a dive reflex could trigger a fatal outcome. To prove the hypothesis in any of the three contingencies described above, one would need to demonstrate the presence of saliva in the larynx or about the nares at necropsy and to show that this had been present at the time of death. This point could be difficult to establish. 12 Collins Street, Melbourne 3000, Australia.
diagnogir
KATE CAMPBELL.
PRECAPILLARY BYPASS AND SUDDEN INFANT DEATH SiR,-The syndrome of sudden unexpected death in infancy is still unexplained. I wish to put forward a hypothesis based on the resemblances between the lung picture in this syndrome and that in the respiratory-distress
syndrome of neonates. In the respiratory-distress syndrome the right-to-left shunt largely takes place in the lungs and 2 necropsy may reveal a patent precapillary bypass. It seems possible that this bypass could reopen sufficiently to cause anoxaemia. This possibility led me to investigate the lungs of a male infant aged 8 months who died unexpectedly in an orphanage. No signs of disease had been noted previously, and the necropsy diagnosis was suffocation. I injected indian ink into the pulmonary artery of one excised lung. (In a normal lung the ink enters easily, and the lung becomes black.) No ink was seen to enter macroscopically, and histological sections showed no ink in the capillaries; there was, however, ink in the precapillary bypasses. The precapillary bypass is formed by bronchial/pulmonary artery anastomoses and arteriovenous anastomo-
ses.3,4 I suggest that a change in vagal tone could trigger the reopening of the bypass. This would be impossible in older children, in whom the bypass is obliterated. Changes in vagal tone could be precipitated by mechanisms such as upper-respiratory-tract infection. Department of Pædiatrics, University of Turku 205 20, Turku 50, Finland.
S. JÄYKKÄ.
SUDDEN DEATHS IN INFANTS
SiR,-Your leader of Nov. 13 asks whether sudden deaths in infants take place in hospital. I have personally seen four cases. Two were in the infants’ ward, one in the special-care unit, and one on the normal newborn service. I believe that other paediatricians have had the same experience. Welsh National School of Medicine, Department of Child Health,
Llandough Hospital, Penarth, Glam. CF6 1XX.
O. P. GRAY.
ASPIRIN-INDUCED HYPOGLYCÆMIA IN A PATIENT ON HÆMODIALYSIS SIR,-We were interested to read the letter by Dr. David and others (Nov. 13, p. 1092). We have drawn attention to the occurrence of spontaneous hypoglycsemia in diabetic patients with renal failure.ó Since only a fasting blood-sugar was measured in their patient (90 mg. per 100 ml.), the possibility of underlying diabetes mellitus does not seem to have been unequivocally excluded.In 1. 2. 3. 4. 5. 6.
Murdock,
this regard, the findings on renal biopsy would be instructive, for the nature of the patient’s kidney disease is not clear from the case-report. Although aspirin may well have been involved in producing hypoglycsmia, alternative possibilities should be considered. However, in the absence of plasma salicylate and insulin determinations it is unlikely that a definitive
A. I., Kidd, B. S. L., Llewellyn, M. A., McReid, M., Swyer, P. R. Biol. Neonat. 1970, 15, 1. Jäykkä, S. P. O. Acta pœdiat. 1958, 47, 484. von Hayek, H. Die menschliche Lunge. Berlin, 1953. Lauweryns, J. De Longvaten. Arscia uitgaven. Brussels, 1962. Block, M. B., Rubenstein, A. H. J. Am. med. Ass. 1970, 213, 1863. Block, M. B., Mako, M., Rubenstein, A. H. Clin. Res. 1971, 14, 685.
can
he marie.
University of Chicago, Department of Medicine, 950 East 59th Street, Chicago, Illinois 60637.
MARSHALL B. BLOCK ARTHUR H. RUBENSTEIN.
CROMOGLYCATE IN ALLERGIC RHINITIS SIR,—Your annotation (Dec. 4, p. 1243) prompts me todescribe a simple method of assessing this drug in allergic rhinitis. This condition is notoriously variable in severity,. and if the drug is tried during a good phase the patient will conclude that it works. I have found it useful to tell the patient to use it four times daily, in one nostril only, for one week. Results are usually clearcut. General adoption of this method could save the N.H.S. a great deal of money, 110 Old Park Ridings, Winchmore Hill, London N.21
I. S. MUIR.
THE SOCIAL FATE OF THE AMPUTEE
SIR,—Mr. Chilvers and Mr. Browse (Nov. 27, p. 1192) record that 11 out of 20 patients who had a unilateral. amputation for ischaemic disease at an elderly age were faced with the double trauma of an amputation and gross disturbance of their environment. 7 of them were admitted to institutions, and while they were waiting they occupied an acute surgical bed for many weeks. It is not generally recognised that a large number of elderly patients are subjected to amputation-more than 3000 a year are treatedby the limb-fitting service. We have therefore made a special study of this problem at Queen Mary’s Hospital, Roehampton, because we feel that the best solution is to return these patients capable of an independent existence to their own homes after the amputation. To this end we have adopted a policy of below-knee amputation wherever possible, and 82% of the amputations performed in our unit are at below-knee level, with a result that in the past four years 39 patients have been returned to their own homes capable of independent existence, many of them in fact living on their own. Only 2 patients who previously lived in their own homes were transferred to geriatric units, and 6 patients, who were in an institution before their amputation, were returned to an institution. The average age of the patients treated at Queen Mary’s Hospital has been 72 years, with the eldest 95 years. To obtain this high proportion of rehabilitated patients we have accepted the necessity that these patients should be retained in hospital until they are capable of an independent existence. This has led to some of these
patients remaining in hospital for as long as six months, but the majority are discharged in a much shorter time and when these patients have been reviewed at home, in, a course of a survey which we are undertaking, it is apparent that it was well worth returning them to their normal existence whenever possible. It is apparent to us that if elderly patients who have had an amputation are not to be relegated to institutional care, facilities must be made available for hospital rehabilitation before they return home. A close cooperation between hospital, general practitioner, social worker, and patient, which is best achieved by a home visit before the patient leaves hospital, and the provision of pylons and prostheses by the limb-fitting service with a minimum of delay, are
1316
important. The cooperation of the patient’s relatives is more likely to be secured when they realise the patient will retain some independence and will not be a total burden on the household. By placing the emphasis on all these factors, we believe the need for geriatric care of these patients can be reduced to a minimum and the quality of their survival can be thereby improved. Queen Mary’s Hospital, Roehampton, London SW15 5PN.
K. P. ROBINSON.
IS SELENIUM A TERATOGEN ?
SIR,-Robertson1 has suggested that selenium might teratogenic in two groups of female workers who weighed out selenite-containing powder-an ingredient have been
in a medium for salmonella culture. Robertson’s observation is consistent with that of Moxon and Rhian 2 who reported that affected chickens in high seleniferous regions have eggs which are either sterile or produce a high percentage of monstrosities. Hadjimarkos3 observed that children who were lifelong residents of the high-selenium areas of Oregon, Wyoming, Montana, and South Dakota have a greater than average susceptibility to dental caries. On the other hand, Holmberg and Ferm 4 reported that sodium selenite, under certain conditions, actually protects hamsters against the teratogenic effects of cadmium and arsenic. Because of the possibility that selenium might also be a teratogen at physiological levels, a study was undertaken to see whether there is a relationship between selenium concentration in the environment and neonatal deaths. High, medium, and low selenium Statesand their respective neonatal death-rates are listed in the figure. The District of Columbia was included in the low-selenium group. Allaway et al.have shown higher blood-selenium in normal people in high-selenium areas and lower bloodselenium in people from low-selenium areas. Populations of these States were found in the 1960 census and neonatal deaths were found in Vital Statistics.1 Neonatal deaths were chosen, since this statistic is most likely to reflect any teratogenic effect. 1. Robertson, D. S. F. Lancet, 1970, i, 518. 2. Moxon, A. L., Rhian, M. Physiol. Rev. 1943, 23, 305. 3. Hadjimarkos, D. M. Lancet, 1970, i, 721. 4. Holmberg, R. E., Ferm, V. H. Archs envir. Hlth, 1969, 18, 6. 5. Kubota, J., Allaway, W. H., Carter, D. L., Cary, E. E., Lazar, V. A. J. agr. Fd Chem. 1967, 15, 448. 6. Allaway, W. H., Kubota, J., Losee, F., Roth, M. Archs envir. Hlth, 1968, 16, 342. 7. Vital Statistics of the United States; Vol. II, part B. United States Department of H.E.W., Public Health Service, National Vital Statistics Division, Washington, 1960.
The high, medium, and low selenium States had average neonatal death-rates and standard errors of 720 ±34-6, 760±24, and 927 28. The differences between the high and medium selenium States and the low-selenium States are highly significant using Student’s t test (P< 0-001). Selenium is an essential trace element necessary for the growth and development of quail, rats, and chickens.a Selenium is probably an essential trace element for human beings as well.9 At physiological levels such as those found in the United States environment, selenium may also be necessary for the proper growth and development of the human embryo. No enhancement of teratogenicity was seen. The inverse relationship found here between neonatal deaths and selenium at physiological levels, and the known teratogenicity of selenium at toxic levels in animals,2 draws an interesting parallel to the inverse relationship reported between selenium occurrence and human cancer mortality.8 At nutritional levels, dietary selenium prevented tumour formation in animals,lO but at dosages approaching chronic poisoning for three years selenium may increase the spontaneous tumours that occur in old rats.9 Division of Laboratory Medicine, Department of Biochemistry, Cleveland Clinic Foundation, Cleveland, Ohio 44106, U.S.A.
RAYMOND
J. SHAMBERGER.
ENTEROCOLITIS FOLLOWING EXCHANGE TRANSFUSION SIR,-In reply to Dr. Super’s letter (Nov. 27, p. 1203), I agree that it is likely that several factors are involved in the complication ileocolitis following exchange transfusion. In 2 of the cases that have occurred in this region sodium bicarbonate 8-5% was not injected into the umbilical vein. The Department of Health is investigating any possible hazards associated with the use of the heating coil, and until it has been passed by them I have discontinued its use. Alder Hey Children’s Eaton
Hospital,
Road,
A. E. MCCANDLESS.
Liverpool L12 2AP.
JUST A MACHINE ? SIR,-Dr. Habershon (Dec. 4, p. 1257) asks this question and states that " it is one of the most important questions for discussion today ". We are not just machines, since the most sophisticated machines that we have developed are simple and crude by comparison with our IS MAN
bodies. The fact that we have learnt so much about ourselves and the universe in the last few moments of our evolution is due to the emergence of disciplined thought that requires that the words and concepts that we use be agreeably defined. When we apply this disciplined thought to the hypothesis that we can be other than we are-i.e., that we have free-will -we find that the evidence, which is very extensive, is entirely against it. Many of us, in the present and previous centuries, who have come to the conclusion that free-will is an illusion have been afraid to accept and broadcast the fact for fear that it might rob life of some of its most precious things and Shamberger, R. J., Willis, C. E. Crit. Rev. clin. Chem. 1971, 2, 211. 9. Schroeder, H. A., Frost, D. V., Balassa, J. J.J. chron. Dis. 1970 23, 227. 10. Shamberger, R. J. J. natn. Cancer Inst. 1970, 44, 931. 8.
Selenium levels in different States, in relation to neonatal death-rate, 1960.