Publ. Hlth, Lond. (1975) 89, 161-162
Sudden Death in Infancy J. M a l c o l m C a m e r o n M.D.. Ph.D.(Glas),, M.R.C.Path., D.M.J.
Professor of Forens/c Med/c/ne, London Hospi~a/ Medica/ Co//ege Out of every thousand deaths in the United Kingdom just over 1 ~ will die during the first year of life, many from gross abnormalities and easily recognizable disease, but of the 99 survivors some 2 ~o at least will die suddenly and unexpectedly from between the beginning and the end of the first year. ln absolute numbers these unexpected deaths probably amount to approximately 1500 to 3000 in the United Kingdom per annum or, as has been expressed by Teare, 1973, more than one-third of all post:neonatal deaths. It has been reported that most infants who die in this manner seem to have been healthy or only mildly unwell on the day or so prior to death, death occurring silently, suddenly and usually unobserved and, more often than not, during sleep; the child being found lifeless, without any evidence of any struggle or violence having been applied. The increasing awareness of this syndrome is now the cause of great anxiety to many mothers and to doctors in general. The aetiology of the cot death, however, remains obscure. There is an allegedly seasonal incidence with a peak in winter months and a low point in August. In the past it has been assumed that more boys were affected than girls but, from the series examined at the London Hospital Medical College, there is no statistical significance to support this assumption. But in the same series as that of Mrs Watson, namely a total of 78 cases, at autopsies carried out within the Department of Forensic Medicine it was considered that of the 71 cases there were 36 sudden deaths in infancy and a miscellaneous group of 32. Three were totally excluded. In other words, there was a total of 68 sudden infant deaths. As a result of further examination, a total of nine cases were excluded from the 71, because some of them were carried out by pathologists other than those within the Department of Forensic Medicine and one or two were criminal cases. The final provisional figures were: sudden deaths in infancy, 34; miscellaneous, 28, making a total of 62. It was arranged that each case, prior to autopsy, should have tomographs (special radiographic examination) made in three-dimensions of the nasopharynx to see whether there was in fact any nasal obstruction causing a mechanical blockage in the airways, which would be in keeping with the views expressed by Professor Cross. At autopsy a rather radical, but modified, technique was used. In order to maintain the features of the child, special care was taken so that no distressful results would be visible to parents. Nevertheless, the turbinates (skin over the bony structures of the nasopharynx) were examined under the microscope, together with other organs. It cannot be stressed too strongly that this survey was commenced with the premise that there was such a condition--sudden death in infancy - - a n d the utmost was done to prove it. What one must realize is that the figure of 62 is far too small to be statistically significant. As a result of the histological examination carried out at post-mortem examination beforehand (totally independent of the sociological examination and interpretation made by Mrs Watson), the results of the examination revealed that only five cases could be found, which could be classified as true sudden deaths in infancy; 57 had died of other causes. Histological examination revealed extensive macroscopically undiagnozable, but microscopically undeniable evidence of inflammatory change affecting the upper and lower respiratory passages and, in some cases, even the
162
J. Malcolm Cameron
heart. Whilst it is recognized that this series is not statistically significant, it must be pointed out that past criticism that the pathological causes of death given by pathologists carrying out autopsies on behalf of the coroner must have been erroneous in order to give an immediate cause of death, cannot be substantlal]y maintained and that, in m a n y cases, they were right and are still right. It is humbly suggested, however, that with such a small number this survey should be continued and furthered in order that a true assessment can be made of the condition. It is also strongly advised that those working on the project should work independently and should in no way be biased by the views expressed by their colleagues and that they only combine after their interpretations have been obtained. It is the considered opinion of the writer that there is such a condition as sudden death in infancy, but that it is not as common as one anticipated it to be and that there are many cases of undetected inflammatory change affecting the child which are not even diagnosed by the general practitioner, or that the child has been recognized as being seriously ill by the parents. This is in no way intended to be a criticism of either the parent or of the general practitioner, for it is the opinion, as a result of looking at the tissues under the microscope, that, no matter what treatment had been given, death was inevitable and, in so saying, it must be assumed that these are in fact sudden deaths in infancy. With regard to the serological (blood grouping) examination of the children, this was only carried out in the deceased and it was noted that there was an increase in blood group B at the expense of blood group A, but the series, as has been stated, was small and unexpected frequencies may not be those of the general English population, for in the East End of London one must consider other non-European families. It must also be noted that there may be more in the expected number of non-secretors but, again, the series is too small and some may have been wrongly classed ~ ~on-secretors owing to insufficient secretory material on the swabs taken from the mouth a n d n o s e , These are all facts which must be considered when planning a future research programme and a further research project.
Sudden Death in Infancy J. M a l c o l m C a m e r o n M.D.. Ph.D.(Glas),, M.R.C.Path., D.M.J.
Professor of Forens/c Med/c/ne, London Hospi~a/ Medica/ Co//ege Out of every thousand deaths in the United Kingdom just over 1 ~ will die during the first year of life, many from gross abnormalities and easily recognizable disease, but of the 99 survivors some 2 ~o at least will die suddenly and unexpectedly from between the beginning and the end of the first year. ln absolute numbers these unexpected deaths probably amount to approximately 1500 to 3000 in the United Kingdom per annum or, as has been expressed by Teare, 1973, more than one-third of all post:neonatal deaths. It has been reported that most infants who die in this manner seem to have been healthy or only mildly unwell on the day or so prior to death, death occurring silently, suddenly and usually unobserved and, more often than not, during sleep; the child being found lifeless, without any evidence of any struggle or violence having been applied. The increasing awareness of this syndrome is now the cause of great anxiety to many mothers and to doctors in general. The aetiology of the cot death, however, remains obscure. There is an allegedly seasonal incidence with a peak in winter months and a low point in August. In the past it has been assumed that more boys were affected than girls but, from the series examined at the London Hospital Medical College, there is no statistical significance to support this assumption. But in the same series as that of Mrs Watson, namely a total of 78 cases, at autopsies carried out within the Department of Forensic Medicine it was considered that of the 71 cases there were 36 sudden deaths in infancy and a miscellaneous group of 32. Three were totally excluded. In other words, there was a total of 68 sudden infant deaths. As a result of further examination, a total of nine cases were excluded from the 71, because some of them were carried out by pathologists other than those within the Department of Forensic Medicine and one or two were criminal cases. The final provisional figures were: sudden deaths in infancy, 34; miscellaneous, 28, making a total of 62. It was arranged that each case, prior to autopsy, should have tomographs (special radiographic examination) made in three-dimensions of the nasopharynx to see whether there was in fact any nasal obstruction causing a mechanical blockage in the airways, which would be in keeping with the views expressed by Professor Cross. At autopsy a rather radical, but modified, technique was used. In order to maintain the features of the child, special care was taken so that no distressful results would be visible to parents. Nevertheless, the turbinates (skin over the bony structures of the nasopharynx) were examined under the microscope, together with other organs. It cannot be stressed too strongly that this survey was commenced with the premise that there was such a condition--sudden death in infancy - - a n d the utmost was done to prove it. What one must realize is that the figure of 62 is far too small to be statistically significant. As a result of the histological examination carried out at post-mortem examination beforehand (totally independent of the sociological examination and interpretation made by Mrs Watson), the results of the examination revealed that only five cases could be found, which could be classified as true sudden deaths in infancy; 57 had died of other causes. Histological examination revealed extensive macroscopically undiagnozable, but microscopically undeniable evidence of inflammatory change affecting the upper and lower respiratory passages and, in some cases, even the
162
J. Malcolm Cameron
heart. Whilst it is recognized that this series is not statistically significant, it must be pointed out that past criticism that the pathological causes of death given by pathologists carrying out autopsies on behalf of the coroner must have been erroneous in order to give an immediate cause of death, cannot be substantlal]y maintained and that, in m a n y cases, they were right and are still right. It is humbly suggested, however, that with such a small number this survey should be continued and furthered in order that a true assessment can be made of the condition. It is also strongly advised that those working on the project should work independently and should in no way be biased by the views expressed by their colleagues and that they only combine after their interpretations have been obtained. It is the considered opinion of the writer that there is such a condition as sudden death in infancy, but that it is not as common as one anticipated it to be and that there are many cases of undetected inflammatory change affecting the child which are not even diagnosed by the general practitioner, or that the child has been recognized as being seriously ill by the parents. This is in no way intended to be a criticism of either the parent or of the general practitioner, for it is the opinion, as a result of looking at the tissues under the microscope, that, no matter what treatment had been given, death was inevitable and, in so saying, it must be assumed that these are in fact sudden deaths in infancy. With regard to the serological (blood grouping) examination of the children, this was only carried out in the deceased and it was noted that there was an increase in blood group B at the expense of blood group A, but the series, as has been stated, was small and unexpected frequencies may not be those of the general English population, for in the East End of London one must consider other non-European families. It must also be noted that there may be more in the expected number of non-secretors but, again, the series is too small and some may have been wrongly classed ~ ~on-secretors owing to insufficient secretory material on the swabs taken from the mouth a n d n o s e , These are all facts which must be considered when planning a future research programme and a further research project.
