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Annotations

TO BURP OR NOT TO BURP ?THERE is something to be said for a short word to

convey the meaning of the phrase " bringing up thewind " as applied to the technical side of infant feeding.In the U.S.A. babies are " burped " during and at theend of feeds ; and this somehow conveys a short, snappysort of drill in contrast to the half-hearted stroking ofthe lower dorsal region which often seems to be theusual contribution of the average nurse or mother to ababy’s postprandial comfort. Dr. Joan Tanner, in a letteron p. 230, speaks of her own ’experiences as a motherand is probably not far off the mark when she statesthat " wind " is the cause of many of the feeding diffi-culties of infancy. Air-swallowing is an inevitableaccompaniment of liquid refreshment. In the earlydays of lactation the infant left too long at an onlypartially functioning breast gulps down more air thanmilk, and if not taught at this early stage the trick ofbringing up the wind will develop a habit of discomfortand refusal to take enough milk when more is available,as Dr. Tanner recounts.

Exactly what this trick consists in is not easy to des-cribe. It must entail some relaxation of the cardia andperhaps a fiick of the diaphragm to give the cardiac endof the stomach the chance to expel the air-bubble there.Clearly the baby must be held upright. After this detailsseem to vary. The object must surely be to give a suddensqueeze to the distended stomach. With one hand or

perhaps the shoulder in the epigastrium, the other handbangs the back on the left side. This should almostcertainly be done two or three times during a feed aswell as at the end. At first sight the stroking-of-the-backmethod would seem to have little to support it, butfarmers maintain that when choosing a calf at themarket, passage of a walking-stick along the animal’sspine produces a reflex passage of a stool which can beinspected to exclude an intestinal infection in the prospec-tive purchase. If such a reflex in fact exists, it mightconceivably be found in babies, working in the otherdirection so to speak. Animal studies might throwlight on this and indeed on other aspects of the problemof wind. Do suckling animals also swallow air Do

they bring it up without training It is perhaps signifi-cant that the common position for breast-feeding in thehuman race, at any rate among white peoples, is withthe baby on his back and the head to some extentflexed on the body, whereas in the animal kingdom theanimal either stands or lies prone with the head wellextended. Does this prevent air-swallowing ? Africanmothers often feed their babies with the infant lyingparallel, the head in the mother’s axilla, and the breastgiven by the mother slightly rolling over towards thebaby. In this position is as much air swallowed as inthe more usual European and American method of

holding the baby ? X-ray studies of the gas-bubble inanimals and in human babies fed in various positionsmight help to answer these questions. Air-swallowingis certainly- worse with underfeeding on the breast, andless troublesome with bottle-feeding than with breast-feeding. This explains why discomfort after feeds oftendisappears when the breast-fed baby is weaned on to abottle-with the false deduction that cow’s milk is moredigestible for a particular baby than mother’s milk.

Dr. Tanner has done a useful service in calling attentionto an important part of management of infant-feeding.If discomfort can be prevented, breast-feeding obviouslywill proceed more smoothly and less weaning in theearly months might result from greater care over

burping. If the psychologists are right who attributeaggression in later life to difficulties at the breast, then thequestion of burping is important in national and inter-national affairs. A campaign to study it seems overdue.

THERAPEUTIC USES OF RADIO-ISOTOPES

THE great interest being taken in the use of radio-active isotopes in this country was illustrated by thecrowded meeting at the Royal Society of Medicine

(reported on p. 212) to hear various workers discusstheir experiences in the last two years. It seems clear thatthe essential cooperation between clinician and physicisthas been achieved and that the need to go slowly, main-taining the objective view of the scientist, has beenrealised.

- The two main applications of isotopes in medicineare as tracers and as producers of therapeutic radiation.Tracer methods are used in research and diagnosis, andwhen therapy is proposed its accuracy may also depend ontracer techniques. Dr. Ralston Paterson pointed out thatthe principles involved in the treatment of thyroid cancerwith radioactive iodine are new and differ considerablyfrom those of the standard methods of radiotherapy.When the radioactive isotope I131 is ingested, likeordinary iodine it enters the blood-stream and is thenselectively absorbed by the thyroid. In the thyroid theisotope goes through the usual process of conversion intothyroxine and secretion into the colloid in the acini, andduring this period it is constantly irradiating the cells inand near which it lies. This irradiation may be completelydestructive of all functioning tissue. Such radiation ofthe tissue from within is completely different from thatobtained by placing radium or radioactive cobalt intoholes in living structures or by irradiating the patientfrom outside, but the mechanism of absorption of electro-magnetic radiation and of beta particles is the same.Research has been necessary to find out how far theestablished principles of protection from radiation, tissuetolerance, and calculated dosage can be applied to thisabsorption irradiation.

.

Cancer of the thyroid is now being treated with 1131in Manchester and Sheffield, and at the Royal CancerHospital in London ; but, since selective absorption is

only possible in functional thyroid tissue, only a smallproportion of these cases will respond to the treatment.Out of 17 cases of thyroid cancer examined by tracerdoses of p31 in Manchester, Dr. H. C. Warringtontold the meeting only 2 were found to have tumourswhich concentrated iodine, and both were metastases.Once it has been proved that the tumour absorbs iodineit becomes necessary to eliminate the thyroid, becausenormal thyroid tissue will segregate most of the availableiodine. The aim then is to produce a myxcedematouspatient whose need for thyroxine stimulates the metas-tases derived from thyroid tissue to segregate moreiodine, so that when the isotope is presented to themthey will destroy themselves. The thyroid is best removedsurgically, but if this is impossible a radio-eliminationcan be carried out probably by a single " therapeuticdrink " of 1131. Thereafter further high doses must

probably be given, because only one part of the tumouror one metastasis may be functional at any one time, soeach must be destroyed singly. The therapeutic drinkconsists of 60-70 mC of radio-iodine in water, and ithas very little systemic effect. The other important useof this isotope is in the treatment of thyrotoxicosis.The possibilities of the method are being carefullyinvestigated at Sheffield, and Br. A. G. Macgregoremphasised the value of estimations of the level of I131in the plasma 48 hours after a dose in distinguishingbetween the various thyroid disorders.The therapeutic uses of other radioactive isotopes

are also being explored. Radioactive phosphorus hasalready proved valuable in polycythaemia and leukaemia,and emitters such as radiosodium, which emit beta andgamma rays, have been used for intracavitary treatmentof bladder cancers. In the future it may be possible tofind ways of incorporating radioactive elements insubstances which are selectively absorbed in tumours.

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So far we have only one true example of this process,the absorption of I131 in functioning cancer of the

thyroid-a small gain in itself but one which opens afascinating field of research.

NOMENCLATURE OF FUNGI

THE nomenclature of the medical fungi, never satis-factory, has been complicated by the indiscriminate

coining of new names ; mere mutants have been acceptedand named as new species. Thus an unwieldy synonymyhas grown up. Diddens and Lodder have cited 87

synonyms of Candida albicans (Robin 1853) Berkhout1923, the common thrush fungus ; while Conant putsthe number at 172. Fortunately, few of these synonymsare to be found in current works ; but misunderstandingis sometimes caused by the use of two entirely dissimilarnames for the same species-e.g., Monilia pinoyi forCandida albicans, Torula histolytica for Cryptococcusazeoformans, and ltlicrosporunz felineum for Microsporumcaitis. The decision on what is the valid name of a

fungus must accord with the international rules ofbotanical nomenclature ; and careful research is neededto establish priority.The medical mycology committee of the Medical

Research Council has done a useful service in preparinga list 1 of names recommended for the fungi pathogenicto man and animals in Great Britain. The list gives theapproved names of the fungi with the authorities and themore common synonyms, and the names and synonymsof the associated diseases. There is regrettable lack ofagreement on nomenclature between different countries,and even among groups of medical mycologists inthe same country ; and the publication of this authori-tative list is a step-albeit a small step-towards securingnational and ultimately international agreement.

ULTRA-RAPID TRANSFUSION

A method of giving blood or infusion fluids very rapidly,by forcing them out of the transfusion bottle with

oxygen under pressure, is described by Pierce, Robbins,and Brunschwig.2 These workers have used this methodto administer blood to patients who have collapsedduring extensive surgical operation, transfusing it atrates varying from 100 ml. to about 250 ml. per minute.The need for rapid transfusion in profound " shock "due to haemorrhage or trauma has been appreciatedsince the late war,3 but in this country blood is seldomgiven at rates much above 100 ml. per minute. Fasterrestoration of a depleted blood-volume may have certainadvantages, but the dangers of air embolism 4 and" overloading " associated with rapid transfusion arelikely to be increased. If embolism is to be avoided,the oxygen propulsion method requires the full attentionof a doctor throughout the transfusion, as Pierce et al.say. In considering the possibility of "

overloading "

they remark that " with patients in shock due to blood

loss this danger does not exist at first, but once approxi-mate replacement has been obtained and blood pressures

are near the patient’s normal, care must be exercisedin continuing transfusions." A most important factor,which they do not mention, is the previous state of healthof the patient. Rapid restoration of a depleted blood-volume is one thing in a previously healthy and robustadult, but quite another in a person who has beenill for months or years. Unless there has been adequatepreoperative correction of such abnormalities as anaemia-whose effect on the heart in relation to transfusion

1. Nomenclature of Fungi Pathogenic to Man and Animals : Namesrecommended for use in Great Britain by the medical myco-logy committee of the Medical Research Council. MedicalResearch Council, memorandum no. 23. H.M. StationeryOffice. Pp. 12. 6d.

2. Pierce, V. K., Robbins, G. F., Brunschwig, A. Surg. Gynec. Obstet.1949, 89, 442.

3. Treatment of Wound Shock. Medical Research Council WarMemorandum, no. 1 (2nd ed.), 1944.

4. Lancet, 1949, i, 743.5. Drummond, R. J. Brit. med. J. 1943, ii, 319.

has been described by Sharpey-Schafer 6-even transfu-sions given at the more conservative rates carry somerisk of " overloading." Another point which must beseriously considered is the possibility of defects developingin reducing valves on oxygen cylinders used to control theinflow of oxygen to the transfusion bottle. Such a defectmight be quickly fatal.The value of ultra-rapid transfusion must be proved by

further careful observation before an opinion can beexpressed on the need to use it. Unless it is performedby skilled and experienced operators, aware of its poten-tial dangers, its adoption might well be followed by anincrease in the number of transfusion fatalities. Oftena sufficiently rapid inflow of blood can be obtained byfar simpler and safer methods, such as the use of a

24/10 gauge needle in place of the usual 15/10 gauge needle.END OF AGENISED FLOUR

SINCE Mellanby announced three years ago that

agenised flour can produce hysteria in dogs, and some-what similar symptoms in the rabbit and the ferret,intensive experiments have been made both here 8 andin the U.S.A. to find out whether it has any harmfuleffects on man. Meanwhile, however, the U.S. andCanadian governments have prohibited its use in favourof another flour improver, chlorine dioxide. In -thiscountry a committee was set up, under the chairman-ship of Sir Wilson Jameson and including representativesof the Ministries of Health and Food, the Medical ResearchCouncil, and the milling industry, to consider the wholeproblem and advise on the steps to be taken. Accordingto a statement on another page (227), the committee findsno evidence whatever that the agenised flour is harmful toman, but it recommends that the agene process should bereplaced by treatment with chlorine dioxide as soon asthe necessary equipment can be imported from theUnited States, presumably the only source of supplies.This recommendation has been accepted by the Ministriesof Food and Health and by the milling industry.Assuming that flour improvers are essential if we are

to get the type of bread to which we are accustomed’-and the committee accepts that assumption-thedecision to follow the North American example wasperhaps inevitable. Nevertheless there is an obviousneed for concentrated research to find a biologicalimprover or other form of treatment which by its verynature would be beyond criticism. Chlorine dioxide-hasthe advantage over agene that even in quantities greatlyin excess of the normal treatment of 2530 p.p.m. it -

produces no toxic symptoms in dogs or other animals.The toxicity of agenised flour to dogs must have createddisquiet in many minds, and Sir Wilson Jameson’scommittee was wise to stress twice in its statement thatthere is no evidence that it is harmful to man. Oddlyenough, two earlier public statements-the first in theB.B.C. news bulletins on Jan. 25, based on the MedicalResearch Council report for 1945-48 which was issuedthat day, and the other by Sir Edward Mellanby in abroadcast on Jan. 27-were not so definite.Presumably the agene controversy in its practical

implications is now ended, but the research which it

inspired should make useful additions to pharmacologicalknowledge. In September, 1949, Moran and his col-

leagues 9 at the Cereals Research Station, St. Albans,announced the isolation of a crystalline toxic factor fromagenised zein. The same team have since shown 10 thatthe factor is a new but relatively simple derivative ofmethionine—C5H12N2SO3—with the additional NH and0 probably attached to the S atom. Furthermore, theypoint out that such a molecule can exist in isomeric6. Sharpey-Schafer, E. P. Lancet, 1945, ii, 296.7. Mellanby, E. Brit. med. J. 1946, ii, 885.8. Elithorn, A., Johnson, D. M., Crosskey, M. A. Lancet, 1949, i, 143.9. Bentley, H. R., McDermott, E. E., Pace, J., Whitehead, J. K.,

Moran, T. Nature, Lond. 1949, 164, 438.10. Ibid, 1950, 165, 150.