BRITISH MEDICAL JOURNAL
1415
26 NOVEMBER 1977
demonstrate any benefit from urethral dilatation or urethrotomy; both have gained a place in the treatment regimen of the frequencydysuria syndrome, but it is unwise to lose sight of the fact that no logical basis for such treatment exists. To suggest that urethral surgery is effective a controlled trial of the results of surgery as opposed to other forms of treatment must be forthcoming and a lengthy follow-up undertaken. The comparison of post-mortem histological specimens with those removed at operation will be interesting. Until then fibroelastosis remains a hypothesis as nebulous as "reversible muscle spasm" because of a "local irritative urethral or bladder lesion." H N WHITFIELD J E A WICKHAM Deparumenit of U rology, St Baruholomew's Hospital, London E(C
SIR,-YOU point out in your leading article (3 September, p 593) that rational treatment of urinary tract inflammation depends on differentiating between those who have relapsing or recurrent bacteriuria and those who do not. It would be so had it been demonstrated that these two categories of patient had any other regularly distinguishing feature apart from bactcriuria. As it is the majority of patients described as suffering from urethral syndrome are clinically indistinguishable from the others and are equally ill. Their treatment is more difficult only because, in the absence of bacteriological guidance, the practitioner perforce prescribes urinary antibacterials on a trial-and-error basis. It is still possible to believe that there is one common inflammatory disease of the urinary tract in which significant bacteriuria is an inconstant feature-comparable with "open" and "closed" cases of pulmonary tuberculosis. Those who tell us that bacteriological examination of the urine allows us to separate "true infection" from "urethral syndrome" do not seem to me to have made their case.
able of two of the patients were also typical of chloroquine maculopathy. A feature of the four patients with retinopathy was the difficulty in obtaining a history of chloroquine use. This was not volunteered and even on direct questioning about malaria prophylaxis one patient denied taking any drug until chloroquine itself was named. It seems to be regarded as an article of diet rather than medication. It was also difficult to estimate the total dose, three of the patients taking a few tablets each week and a few more when they had a fever. One patient had been taking Flavoquine (a French product) two tablets weekly for five years. There seems little doubt that chloroquine used in malaria prophylaxis can cause retinopathy, although it must be admitted that excessive self-overdosage may be a contributory factor. I would agree with your expert that a safer drug may be needed for long-term malaria prophylaxis. J H KELSEY London VI I Appleton, B, et al, Military Medicine, 1973, 138, 225. 2 Trojan, H J, pcrsonal communication. Schmidt, B. ISCERG Symposium, Ghent. In press.
3
Role of the hospital in primary paediatric care
SIR,-There are interesting figures in the letter from Dr M J Robinson and his colleagues (5 November, p 1215) which encourage a sense of proportion in the discussion concerning the role of hospitals in primary care. During one week 212 children from a population of approximately 40 000 children attended the accident and emergency department at St Thomas's Hospital without referral from a general practitioner. Although figures from different practices vary, the second national morbidity survey' showed an average consultation rate of 3-01 consultations per patient per year. Moreover, the figures for the 0-14 age group showed a higher consultation rate than any other age group. So it would be a conservative estimate to N B EASTWOOD suggest that a population of 40 000 children Oulton Broad, would expect to see a primary care doctor Lowestoft, Suffolk (whether in general practice or hospital) 120 000 times in a year. This in turn suggests that during the week that the survey was Prolonged malaria prophylaxis carried out at St Thomas's there were 2308 SIR,-I would like to comment on the discus- consultations involving children in the district sion (12 November, p 1287) about the oculfTre served by the hospital. In other words, while safety of chloroquine when used for malaria 212 children were seen at St Thomas's it is prophylaxis. It has been stated that at the probable that in the same period 2092 consuldosage required there are no ocular effects.' tations took place in general practice in the The manufacturers of the various drugs advise same district. Food for thought. ophthalmic examination after three years of R V H JONES continuous use. However, there is no test that will reliably predict the likelihood of retino- Seaton, Devon pathy, and blinding retinopathy may develop Otlice of Population Censuses and Surveys, Morbi(dity after chloroquine has been discontinued. Statistics fromti General Pracltice: Second Naltionial Stuidy 1.970-71. London, HMSO, 1974. Recently reports have appeared of chloroquine retinopathy developing during its use for malaria prophylaxis.'; During the past three years five patients SIR,-While we would not dispute that "homefrom West Africa have been referred to the based schemes involving increased health electrodiagnostic clinic of Moorfields Eye visitor and nursing supervision of 'problem' Hospital for investigation of loss of vision. families can make a real impression on morAll had been taking chloroquine for malaria tality and morbidity" (Dr T Waterston, prophylaxis over several years. Four of them 15 October, p 1021) there are other factors had electrical retinal responses typically found operating in Sheffield which may well have in chloroquine retinopathy. One had normal contributed to the reduction in infant morretinal responses, but he was also on treatment tality rates. One of the most important of with ethambutol. Fundus photographs avail- these factors is the existence in Sheffield of
a paediatric casualty department which has a 24-hour "open door" policy. In a recent study of 831 children under the age of 2 years attending this department 32 5 attended with acute or subacute medical conditions. Over half of these children with medical conditions came to the department because of their parents' inability to contact the family doctor or because of dissatisfaction with his care. Ten children came because their parents did not have a family doctor. The department in Sheffield has two main roles in the treatment of medical conditions in young children, both of which are encouraged. Firstly, parents who cannot find medical care elsewhere can seek alternative care, and, secondly, family doctors may refer children about whom they are concerned, knowing that there is quick and easy access to specialist paediatric care. We agree that the medical care in such a department may not be optimal, because parents may encounter relatively junior doctors who are strangers or because follow-up may be limited, but these factors can be minimised by the addition of more senior paediatrically trained personnel to the staff and by establishing links with social workers, health visitors, and general practitioners in the
community. Although the responsibility for primary care must in the main rest with the family doctor,
paediatric casualty departments can have a valuable supporting role which is particularly acceptable to "young problem families" who may not be registered with, or may be reluctant to consult, family doctors. A L JAY J R OAKLEY Children's Hospital, Sheffield
SI units and acidity SIR,-It is difficult to support the suggestion by Dr P J Tomlin (24 September, p 833) that the use of the Systeme International (SI) has led to problems in the interpretation of acid-base data, although it is apparent that people are still confused by the logarithmic pH notation. Thus Dr Tomlin makes an arithmetic average from the sum of logarithms (pH) and then not surprisingly arrives at a different result when he averages the sum of the corresponding antilogarithms. Equally if one wishes to determine a "normal range" for plasma pH one must first antilog the pH values individually and plot out the numbers as a histogram to see whether the distribution is of a simple Gaussian type, in which case a standard deviation may be calculated; if the scatter is skewed or bimodal a more complex approach is needed. It should be borne in mind that there are four different ways of expressing acidity within the SI. The most familiar is pH itself, which has the drawback of being a dimensionless negative logarithm as well as being anomalous in some other less important ways.' The second way, which is well known to clinical biochemists but which Dr Tomlin seems to disapprove of, is to express H ion as a concentration in nmol/l from (antilog 9-pH). This is an approximation frowned on by some physical chemists; its use is justified by our great familiarity with concentration measurements in clinical biochemistry and by its value in aiding our understanding the treatment of severe metabolic acidosis with sodium
BRITISH MEDICAL
1416
JOURNAL
26
NOVEMBER
1977
did not appear until seven years later. It was only then fully appreciated that I had bilateral Meniere's disease. I was not much encouraged by your leading article on "Surgery for # '. .t' 'A Meniere's disease" (15 January, p 124), but did have an endolymphatic sac drainage operation in March, which has been of enormous benefit. It has restored my hearing from 30-50 dB to within normal limits and abolished vertigo. It is for this reason that I would urge colleagues presented with vertiginous children to examine the hearing also in order not to miss a condition which may now be helped in certain cases. Also, it is all too easy to dismiss vertigo as "benign," but during my childhood attacks I narrowly escaped injury on more than one occasion. Regarding treatinformation about this complex matter are ment of other causes of vertigo, sedatives and referred to Professor Siggaard-Andersen's antiemetics can do a great deal to alleviate the distress of persistent nausea and vomiting contributions cited below.' s This would appear to be an unacceptable while the condition lasts. risk and the knife should be either withdrawn P J N HOWORTH PATRICIA M SARTER or modified to embody a guard. Department of Chemical Pathology, bicarbonate (or sodium hydroxide) and severe metabolic alkalosis with hydrochloric acid.2 When acid or alkali is administered therapeutically in 50-100-mmol quantities it is rational to express their impact on the patient in the same way. There are two less familiar ways of expressing acidity within the SI. The most scientifically rigorous is to express acidity in terms of the chemical potential of H ion; the SI unit for energy, the joule, is used for this purpose so that normal arterial plasma acidity becomes - 44-23 to - 43-76 kJ/mol. J One can easily imagine that this unit would not be acceptable in ordinary medical use. The fourth term for acidity is the concentration of free H ions in nmol/l derived from pH in a stricter manner than indicated above. Readers seeking more
..
Nantwich, Cheshire
King's College Hospital, London SE5
2
Siggaard-Andersen, 0, Scandinavian J7ournal of Clinical and Laboratory Investigation, 1977, 37, suppl 146, p 7. Worthley, L I G, British Journal of Anaesthesia, 1977, 49, 811. Siggaard-Andersen, 0, Blood pH, Gases, and Electrolytes, ed R A Durst, p 1. Washington, DC, National Bureau of Standards Special Publication No 450, 1977.
Tetrabenazine in Huntington's chorea
SIR,-We have just come across a most remarkable misquotation in the paper on this subject by Drs C H Hawkes and C H Nourse (28 May, p 1391). It is said there that we "have expressed reservations about tetrabenazine in Huntington's chorea, suggesting that the risks of depression and drug-induced Parkinsonism outweigh the advantages of its antichoreic action." We made no such point in our paper' but on the contrary said that depression is common in Huntington's chorea and it is difficult to be certain whether it is caused by the drug. Parkinsonism was also not noted in our series. We suggested instead that postural hypotension and dysphagia were the serious side effects which require careful supervision. C Y HUANG C ELLIOTT Lidcombe Hospital,
Lidcombe,
New South Wales
'Huang, C Y, et al, Medical 1976, 1, 583.
J7ournal of Australia,
ANDREw K MARSDEN MICHAEL W FLOWERS Accident and Emergency Department,
Vertigo and the pill
SIR,-I have read with interest your leading article on the incidence of vertigo in children (5 November, p 1173). My experience as an otolaryngologist has led me to believe that there are many causes of vertigo, especially in young people, which have not been recognised so far. The common causes of labyrinthine vertigo such as Meniere's disease or labyrinthitis usually occur in the older age groups, but in my personal practice I have met with an increasing number of young women who have suffered from true vertigo. Examination of their respiratory tract has not shown evidence of disease in the ears, nor has there been very much in the way of deafness or disorder of labyrinthine function as shown on an electronystagmograph. There has been one common thread in all these patients and that is that most of them are young women in their 20s and 30s taking a contraceptive pill. They have often related the onset of the symptoms to the time when they began taking the pill. In many cases I have persuaded the patient to discontinue the pill and perhaps adopt an alternative method of contraception and the incidence of vertigo has subsided. An attempt was made to gain the co-operation of a family planning clinic to send patients along who are on the pill with a view to testing their hearing as well as their labyrinthine function, but unfortunately most of them were unwilling to submit to such an investigation and it had to be abandoned. J SIEGLER
Vertigo in children
SIR,-I should like to mention another possible cause of vertigo in children which was omitted from your leading article (5 November, p 1173)-namely, Meniere's disease. I fully appreciate that this is extremely rare in childhood, but it is important because of the potential damage to hearing. At the age of 7 I suffered a number of severe attacks of vertigo and subsequently became deaf in one ear. By the time this was brought to medical attention there was profound hearing loss, and anyway probably nothing much could have been done then. At the age of 21 tinnitus and distortion of hearing appeared in the other ear, but vertigo
Liverpool
A dangerous kitchen tool
SIR,-We wish to draw attention to a possible danger from the use of the currently popular and reputable types of freezer knife. These are used to cut frozen foods and to chip away ice, when the knife is held as a dagger. As can be seen from the illustration, this exposes the hand to injury if the grip slips down on to the blade. A housewife aged 53 attended this department with a laceration of the little finger of the right hand sustained in this way which severed both flexor tendons and one digital nerve.
General Infirmary, Leeds
Anti-e and vertical transmission of hepatitis B surface antigen SIR, Okada and his colleagues' provided evidence that hepatitis Be antigen (HBeAg) may be used to predict transmission, and anti-HBe the absence of transmission, of hepatitis B virus from asymptomatic carrier mothers to children. The same group of workers2 found that HBsAg-specific DNA polymerase activity was invariably present in serum samples of asymptomatic carriers containing HBeAg but was not detectable in serum samples containing anti-HBe. The lack of infectivity of anti-HBe-containing HBsAgpositive serum has, however, recently been questioned. Berquist and his colleagues3 were able to produce experimental hepatitis B in a chimpanzee by inoculating it with anti-HBecontaining HBsAg-positive human serum. In Glasgow during the last 18 months we have followed up eight asymptomatic carrier mothers and their eight children over a period ranging from three to 13 months. Of these, two babies, both male, developed HBs-antigenaemia at the age of 3 months. One baby born to a mother whose serum contained HBeAg had no clinical or biochemical evidence of hepatitis and later became a persistent HBsAg carrier. The other baby born to a mother whose serum contained anti-HBe at the time of delivery subsequently developed acute icteric hepatitis with peak serum bilirubin at 116 ,tmol/l, peak aspartic (AST) and alanine (ALT) aminotransferases at 3945 and 1830 U/I respectively. He made an uneventful clinical and biochemical recovery and cleared the circulating antigen 62 days after its initial appearance. Three months later antibody to HBsAg (anti-HBs) was demonstrated in his serum. The most probable source of this infection would appear to be the mother (as the baby was subtype ay, mother subtype ay, and father negative for both antigen and antibody). Gerety4 also reported a similar case of hepatitis B in an infant born to an asymptomatic carrier mother whose serum contained anti-HBe. Our evidence and that of Gerety indicate that carriers of hepatitis B surface antigen who are positive for anti-HBe cannot be regarded as totally non-infectious, at least in the vertical transmission situation, although the probability of an anti-HBe-positive mother transmitting the infection to her offspring may be
1415
26 NOVEMBER 1977
demonstrate any benefit from urethral dilatation or urethrotomy; both have gained a place in the treatment regimen of the frequencydysuria syndrome, but it is unwise to lose sight of the fact that no logical basis for such treatment exists. To suggest that urethral surgery is effective a controlled trial of the results of surgery as opposed to other forms of treatment must be forthcoming and a lengthy follow-up undertaken. The comparison of post-mortem histological specimens with those removed at operation will be interesting. Until then fibroelastosis remains a hypothesis as nebulous as "reversible muscle spasm" because of a "local irritative urethral or bladder lesion." H N WHITFIELD J E A WICKHAM Deparumenit of U rology, St Baruholomew's Hospital, London E(C
SIR,-YOU point out in your leading article (3 September, p 593) that rational treatment of urinary tract inflammation depends on differentiating between those who have relapsing or recurrent bacteriuria and those who do not. It would be so had it been demonstrated that these two categories of patient had any other regularly distinguishing feature apart from bactcriuria. As it is the majority of patients described as suffering from urethral syndrome are clinically indistinguishable from the others and are equally ill. Their treatment is more difficult only because, in the absence of bacteriological guidance, the practitioner perforce prescribes urinary antibacterials on a trial-and-error basis. It is still possible to believe that there is one common inflammatory disease of the urinary tract in which significant bacteriuria is an inconstant feature-comparable with "open" and "closed" cases of pulmonary tuberculosis. Those who tell us that bacteriological examination of the urine allows us to separate "true infection" from "urethral syndrome" do not seem to me to have made their case.
able of two of the patients were also typical of chloroquine maculopathy. A feature of the four patients with retinopathy was the difficulty in obtaining a history of chloroquine use. This was not volunteered and even on direct questioning about malaria prophylaxis one patient denied taking any drug until chloroquine itself was named. It seems to be regarded as an article of diet rather than medication. It was also difficult to estimate the total dose, three of the patients taking a few tablets each week and a few more when they had a fever. One patient had been taking Flavoquine (a French product) two tablets weekly for five years. There seems little doubt that chloroquine used in malaria prophylaxis can cause retinopathy, although it must be admitted that excessive self-overdosage may be a contributory factor. I would agree with your expert that a safer drug may be needed for long-term malaria prophylaxis. J H KELSEY London VI I Appleton, B, et al, Military Medicine, 1973, 138, 225. 2 Trojan, H J, pcrsonal communication. Schmidt, B. ISCERG Symposium, Ghent. In press.
3
Role of the hospital in primary paediatric care
SIR,-There are interesting figures in the letter from Dr M J Robinson and his colleagues (5 November, p 1215) which encourage a sense of proportion in the discussion concerning the role of hospitals in primary care. During one week 212 children from a population of approximately 40 000 children attended the accident and emergency department at St Thomas's Hospital without referral from a general practitioner. Although figures from different practices vary, the second national morbidity survey' showed an average consultation rate of 3-01 consultations per patient per year. Moreover, the figures for the 0-14 age group showed a higher consultation rate than any other age group. So it would be a conservative estimate to N B EASTWOOD suggest that a population of 40 000 children Oulton Broad, would expect to see a primary care doctor Lowestoft, Suffolk (whether in general practice or hospital) 120 000 times in a year. This in turn suggests that during the week that the survey was Prolonged malaria prophylaxis carried out at St Thomas's there were 2308 SIR,-I would like to comment on the discus- consultations involving children in the district sion (12 November, p 1287) about the oculfTre served by the hospital. In other words, while safety of chloroquine when used for malaria 212 children were seen at St Thomas's it is prophylaxis. It has been stated that at the probable that in the same period 2092 consuldosage required there are no ocular effects.' tations took place in general practice in the The manufacturers of the various drugs advise same district. Food for thought. ophthalmic examination after three years of R V H JONES continuous use. However, there is no test that will reliably predict the likelihood of retino- Seaton, Devon pathy, and blinding retinopathy may develop Otlice of Population Censuses and Surveys, Morbi(dity after chloroquine has been discontinued. Statistics fromti General Pracltice: Second Naltionial Stuidy 1.970-71. London, HMSO, 1974. Recently reports have appeared of chloroquine retinopathy developing during its use for malaria prophylaxis.'; During the past three years five patients SIR,-While we would not dispute that "homefrom West Africa have been referred to the based schemes involving increased health electrodiagnostic clinic of Moorfields Eye visitor and nursing supervision of 'problem' Hospital for investigation of loss of vision. families can make a real impression on morAll had been taking chloroquine for malaria tality and morbidity" (Dr T Waterston, prophylaxis over several years. Four of them 15 October, p 1021) there are other factors had electrical retinal responses typically found operating in Sheffield which may well have in chloroquine retinopathy. One had normal contributed to the reduction in infant morretinal responses, but he was also on treatment tality rates. One of the most important of with ethambutol. Fundus photographs avail- these factors is the existence in Sheffield of
a paediatric casualty department which has a 24-hour "open door" policy. In a recent study of 831 children under the age of 2 years attending this department 32 5 attended with acute or subacute medical conditions. Over half of these children with medical conditions came to the department because of their parents' inability to contact the family doctor or because of dissatisfaction with his care. Ten children came because their parents did not have a family doctor. The department in Sheffield has two main roles in the treatment of medical conditions in young children, both of which are encouraged. Firstly, parents who cannot find medical care elsewhere can seek alternative care, and, secondly, family doctors may refer children about whom they are concerned, knowing that there is quick and easy access to specialist paediatric care. We agree that the medical care in such a department may not be optimal, because parents may encounter relatively junior doctors who are strangers or because follow-up may be limited, but these factors can be minimised by the addition of more senior paediatrically trained personnel to the staff and by establishing links with social workers, health visitors, and general practitioners in the
community. Although the responsibility for primary care must in the main rest with the family doctor,
paediatric casualty departments can have a valuable supporting role which is particularly acceptable to "young problem families" who may not be registered with, or may be reluctant to consult, family doctors. A L JAY J R OAKLEY Children's Hospital, Sheffield
SI units and acidity SIR,-It is difficult to support the suggestion by Dr P J Tomlin (24 September, p 833) that the use of the Systeme International (SI) has led to problems in the interpretation of acid-base data, although it is apparent that people are still confused by the logarithmic pH notation. Thus Dr Tomlin makes an arithmetic average from the sum of logarithms (pH) and then not surprisingly arrives at a different result when he averages the sum of the corresponding antilogarithms. Equally if one wishes to determine a "normal range" for plasma pH one must first antilog the pH values individually and plot out the numbers as a histogram to see whether the distribution is of a simple Gaussian type, in which case a standard deviation may be calculated; if the scatter is skewed or bimodal a more complex approach is needed. It should be borne in mind that there are four different ways of expressing acidity within the SI. The most familiar is pH itself, which has the drawback of being a dimensionless negative logarithm as well as being anomalous in some other less important ways.' The second way, which is well known to clinical biochemists but which Dr Tomlin seems to disapprove of, is to express H ion as a concentration in nmol/l from (antilog 9-pH). This is an approximation frowned on by some physical chemists; its use is justified by our great familiarity with concentration measurements in clinical biochemistry and by its value in aiding our understanding the treatment of severe metabolic acidosis with sodium
BRITISH MEDICAL
1416
JOURNAL
26
NOVEMBER
1977
did not appear until seven years later. It was only then fully appreciated that I had bilateral Meniere's disease. I was not much encouraged by your leading article on "Surgery for # '. .t' 'A Meniere's disease" (15 January, p 124), but did have an endolymphatic sac drainage operation in March, which has been of enormous benefit. It has restored my hearing from 30-50 dB to within normal limits and abolished vertigo. It is for this reason that I would urge colleagues presented with vertiginous children to examine the hearing also in order not to miss a condition which may now be helped in certain cases. Also, it is all too easy to dismiss vertigo as "benign," but during my childhood attacks I narrowly escaped injury on more than one occasion. Regarding treatinformation about this complex matter are ment of other causes of vertigo, sedatives and referred to Professor Siggaard-Andersen's antiemetics can do a great deal to alleviate the distress of persistent nausea and vomiting contributions cited below.' s This would appear to be an unacceptable while the condition lasts. risk and the knife should be either withdrawn P J N HOWORTH PATRICIA M SARTER or modified to embody a guard. Department of Chemical Pathology, bicarbonate (or sodium hydroxide) and severe metabolic alkalosis with hydrochloric acid.2 When acid or alkali is administered therapeutically in 50-100-mmol quantities it is rational to express their impact on the patient in the same way. There are two less familiar ways of expressing acidity within the SI. The most scientifically rigorous is to express acidity in terms of the chemical potential of H ion; the SI unit for energy, the joule, is used for this purpose so that normal arterial plasma acidity becomes - 44-23 to - 43-76 kJ/mol. J One can easily imagine that this unit would not be acceptable in ordinary medical use. The fourth term for acidity is the concentration of free H ions in nmol/l derived from pH in a stricter manner than indicated above. Readers seeking more
..
Nantwich, Cheshire
King's College Hospital, London SE5
2
Siggaard-Andersen, 0, Scandinavian J7ournal of Clinical and Laboratory Investigation, 1977, 37, suppl 146, p 7. Worthley, L I G, British Journal of Anaesthesia, 1977, 49, 811. Siggaard-Andersen, 0, Blood pH, Gases, and Electrolytes, ed R A Durst, p 1. Washington, DC, National Bureau of Standards Special Publication No 450, 1977.
Tetrabenazine in Huntington's chorea
SIR,-We have just come across a most remarkable misquotation in the paper on this subject by Drs C H Hawkes and C H Nourse (28 May, p 1391). It is said there that we "have expressed reservations about tetrabenazine in Huntington's chorea, suggesting that the risks of depression and drug-induced Parkinsonism outweigh the advantages of its antichoreic action." We made no such point in our paper' but on the contrary said that depression is common in Huntington's chorea and it is difficult to be certain whether it is caused by the drug. Parkinsonism was also not noted in our series. We suggested instead that postural hypotension and dysphagia were the serious side effects which require careful supervision. C Y HUANG C ELLIOTT Lidcombe Hospital,
Lidcombe,
New South Wales
'Huang, C Y, et al, Medical 1976, 1, 583.
J7ournal of Australia,
ANDREw K MARSDEN MICHAEL W FLOWERS Accident and Emergency Department,
Vertigo and the pill
SIR,-I have read with interest your leading article on the incidence of vertigo in children (5 November, p 1173). My experience as an otolaryngologist has led me to believe that there are many causes of vertigo, especially in young people, which have not been recognised so far. The common causes of labyrinthine vertigo such as Meniere's disease or labyrinthitis usually occur in the older age groups, but in my personal practice I have met with an increasing number of young women who have suffered from true vertigo. Examination of their respiratory tract has not shown evidence of disease in the ears, nor has there been very much in the way of deafness or disorder of labyrinthine function as shown on an electronystagmograph. There has been one common thread in all these patients and that is that most of them are young women in their 20s and 30s taking a contraceptive pill. They have often related the onset of the symptoms to the time when they began taking the pill. In many cases I have persuaded the patient to discontinue the pill and perhaps adopt an alternative method of contraception and the incidence of vertigo has subsided. An attempt was made to gain the co-operation of a family planning clinic to send patients along who are on the pill with a view to testing their hearing as well as their labyrinthine function, but unfortunately most of them were unwilling to submit to such an investigation and it had to be abandoned. J SIEGLER
Vertigo in children
SIR,-I should like to mention another possible cause of vertigo in children which was omitted from your leading article (5 November, p 1173)-namely, Meniere's disease. I fully appreciate that this is extremely rare in childhood, but it is important because of the potential damage to hearing. At the age of 7 I suffered a number of severe attacks of vertigo and subsequently became deaf in one ear. By the time this was brought to medical attention there was profound hearing loss, and anyway probably nothing much could have been done then. At the age of 21 tinnitus and distortion of hearing appeared in the other ear, but vertigo
Liverpool
A dangerous kitchen tool
SIR,-We wish to draw attention to a possible danger from the use of the currently popular and reputable types of freezer knife. These are used to cut frozen foods and to chip away ice, when the knife is held as a dagger. As can be seen from the illustration, this exposes the hand to injury if the grip slips down on to the blade. A housewife aged 53 attended this department with a laceration of the little finger of the right hand sustained in this way which severed both flexor tendons and one digital nerve.
General Infirmary, Leeds
Anti-e and vertical transmission of hepatitis B surface antigen SIR, Okada and his colleagues' provided evidence that hepatitis Be antigen (HBeAg) may be used to predict transmission, and anti-HBe the absence of transmission, of hepatitis B virus from asymptomatic carrier mothers to children. The same group of workers2 found that HBsAg-specific DNA polymerase activity was invariably present in serum samples of asymptomatic carriers containing HBeAg but was not detectable in serum samples containing anti-HBe. The lack of infectivity of anti-HBe-containing HBsAgpositive serum has, however, recently been questioned. Berquist and his colleagues3 were able to produce experimental hepatitis B in a chimpanzee by inoculating it with anti-HBecontaining HBsAg-positive human serum. In Glasgow during the last 18 months we have followed up eight asymptomatic carrier mothers and their eight children over a period ranging from three to 13 months. Of these, two babies, both male, developed HBs-antigenaemia at the age of 3 months. One baby born to a mother whose serum contained HBeAg had no clinical or biochemical evidence of hepatitis and later became a persistent HBsAg carrier. The other baby born to a mother whose serum contained anti-HBe at the time of delivery subsequently developed acute icteric hepatitis with peak serum bilirubin at 116 ,tmol/l, peak aspartic (AST) and alanine (ALT) aminotransferases at 3945 and 1830 U/I respectively. He made an uneventful clinical and biochemical recovery and cleared the circulating antigen 62 days after its initial appearance. Three months later antibody to HBsAg (anti-HBs) was demonstrated in his serum. The most probable source of this infection would appear to be the mother (as the baby was subtype ay, mother subtype ay, and father negative for both antigen and antibody). Gerety4 also reported a similar case of hepatitis B in an infant born to an asymptomatic carrier mother whose serum contained anti-HBe. Our evidence and that of Gerety indicate that carriers of hepatitis B surface antigen who are positive for anti-HBe cannot be regarded as totally non-infectious, at least in the vertical transmission situation, although the probability of an anti-HBe-positive mother transmitting the infection to her offspring may be
