473
INFANTILE SPASMS AND CYTOMEGALOVIRUS INFECTION
SIR,—Dr Midulla and his colleagues’
statement (Aug. 14, p. have been published of cytomegalovirus c Bi B) infection in infants with infantile spasms since the orional report by Feldman and Schwartz’ is not true. I reported the isolation of c.m.v. from 6 out of 3infants, 11 llith hypsarrythmia, in 1969.2 However, virus was also isolated from 10% of age-matched infants with non-neurological illnesses admitted to the same hospital. Encouraging as these results seemed to be, the differences were not statistically significant for the numbers of patients in the study. c.M.v. is commonly isolated from infants under a year old, most of the infections occurring at the time of birth or in the early postnatal period and originating probably in the mother who reactivated her latent infection during pregnancy. Large numbers of cases must therefore be investigated, virologically and immunologically, together with proper matched controls to obtain convincing evidence of setiological association. I agree that more work
r:’1 that
no cases
is needed. Department of Virology, St George’s Hospital Medical School,
H. STERN
London SW1
patients, in whom a strong clinical suspicion of pyloric stenosis existed but where initially a pyloric tumour could not be palpated, this method has been used. Only under light general anaesthesia did the tumour become palpable; pyloromyotomy was successful. Neither false negative nor false positive examinations were encountered. The simplicity, rapidity, accuracy, and safety of this method encourages us to advocate examination under anaesthesia to verify the diagnosis of pyloric stenosis in doubtful
cases.
Departments of Pædiatric Surgery and Anæsthesia, Hadassah University Hospital, Jerusalem, Israel
H. FREUND Y. BERLATZKY R. KATZENELSON M. SCHILLER
RED-BLOOD-CELL LEVELS AND LITHIUM TOXICITY
SIR,-Correspondence from Mendels et aU and Rybakowski and Strzyzewski 2 indicates some disagreement regarding the correlation of red-blood-cell/plasma lithium ratios with response to lithium prophylaxis. However, whether or not redblood-cell lithium levels have a bearing on therapeutic response, there is preliminary evidence34 that they can relate to the incidence of lithium side-effects. We can support these preliminary findings. a group of 77 patients receiving lithium prophylactically, detected 9 patients (3 female) exhibiting persistent minor lithium side-effects (polyuria, polydipsia, and fine tremor of the hands). The remaining 68 patients (50 female) showed no evidence of lithium toxicity and, for the purposes of this study,
In
DIAGNOSIS OF PYLORIC STENOSIS
SIR,—Infantile hypertrophic pyloric stenosis is the
we
most
intra-abdominal abnormality requiring surgical correction during infancy. The diagnosis of pyloric stenosis is made primarily by a typical history, the physical findings of gastric waves, and a palpable pyloric tumour. A palpable tumour is the most important finding in establishing diagnosis. In experienced hands, a tumour may be palpated in 70-90% of cases,H When the diagnosis is uncertain clinically, confirmation is usually obtained by upper gastrointestinal X-ray. Lately there has been a tendency to rely upon X-ray examinations rather than careful search for the pyloric tumour.. Fluoroscopic upper gastrointestinal study in infants with pyloric stenosis is an unwarranted exposure to radiation, an unnecessary expense, and may be misleading,6 as shown by an error-rate of 11. 1% in Cremin’s patients3 and of 4 5% in Shuman’s series.’ Since the radiological examination is difficult, lasts about an hour, and is liable to error, we would like to suggest a simpler, safer, and more reliable method for the diagnosis of pyloric stenosis in questionable cases. In infants where there is a strong clinical suspicion but the pvloric tumour is not palpable (especially in robust and wellnourished infants in whom adequate abdominal palpation is difficult, or when the obstruction is of long standing and the tumour hes posteriorly), we examine the patient under mild general anæsthesia. The infant suspected of having pyloric stenosis but without palpable tumour is prepared as for surgery by fluid replacement, repair of metabolic alkalosis, and nasogastric suction. General anaesthesia is induced and maintained with halothane 1-2
INFANTILE SPASMS AND CYTOMEGALOVIRUS INFECTION
SIR,—Dr Midulla and his colleagues’
statement (Aug. 14, p. have been published of cytomegalovirus c Bi B) infection in infants with infantile spasms since the orional report by Feldman and Schwartz’ is not true. I reported the isolation of c.m.v. from 6 out of 3infants, 11 llith hypsarrythmia, in 1969.2 However, virus was also isolated from 10% of age-matched infants with non-neurological illnesses admitted to the same hospital. Encouraging as these results seemed to be, the differences were not statistically significant for the numbers of patients in the study. c.M.v. is commonly isolated from infants under a year old, most of the infections occurring at the time of birth or in the early postnatal period and originating probably in the mother who reactivated her latent infection during pregnancy. Large numbers of cases must therefore be investigated, virologically and immunologically, together with proper matched controls to obtain convincing evidence of setiological association. I agree that more work
r:’1 that
no cases
is needed. Department of Virology, St George’s Hospital Medical School,
H. STERN
London SW1
patients, in whom a strong clinical suspicion of pyloric stenosis existed but where initially a pyloric tumour could not be palpated, this method has been used. Only under light general anaesthesia did the tumour become palpable; pyloromyotomy was successful. Neither false negative nor false positive examinations were encountered. The simplicity, rapidity, accuracy, and safety of this method encourages us to advocate examination under anaesthesia to verify the diagnosis of pyloric stenosis in doubtful
cases.
Departments of Pædiatric Surgery and Anæsthesia, Hadassah University Hospital, Jerusalem, Israel
H. FREUND Y. BERLATZKY R. KATZENELSON M. SCHILLER
RED-BLOOD-CELL LEVELS AND LITHIUM TOXICITY
SIR,-Correspondence from Mendels et aU and Rybakowski and Strzyzewski 2 indicates some disagreement regarding the correlation of red-blood-cell/plasma lithium ratios with response to lithium prophylaxis. However, whether or not redblood-cell lithium levels have a bearing on therapeutic response, there is preliminary evidence34 that they can relate to the incidence of lithium side-effects. We can support these preliminary findings. a group of 77 patients receiving lithium prophylactically, detected 9 patients (3 female) exhibiting persistent minor lithium side-effects (polyuria, polydipsia, and fine tremor of the hands). The remaining 68 patients (50 female) showed no evidence of lithium toxicity and, for the purposes of this study,
In
DIAGNOSIS OF PYLORIC STENOSIS
SIR,—Infantile hypertrophic pyloric stenosis is the
we
most
intra-abdominal abnormality requiring surgical correction during infancy. The diagnosis of pyloric stenosis is made primarily by a typical history, the physical findings of gastric waves, and a palpable pyloric tumour. A palpable tumour is the most important finding in establishing diagnosis. In experienced hands, a tumour may be palpated in 70-90% of cases,H When the diagnosis is uncertain clinically, confirmation is usually obtained by upper gastrointestinal X-ray. Lately there has been a tendency to rely upon X-ray examinations rather than careful search for the pyloric tumour.. Fluoroscopic upper gastrointestinal study in infants with pyloric stenosis is an unwarranted exposure to radiation, an unnecessary expense, and may be misleading,6 as shown by an error-rate of 11. 1% in Cremin’s patients3 and of 4 5% in Shuman’s series.’ Since the radiological examination is difficult, lasts about an hour, and is liable to error, we would like to suggest a simpler, safer, and more reliable method for the diagnosis of pyloric stenosis in questionable cases. In infants where there is a strong clinical suspicion but the pvloric tumour is not palpable (especially in robust and wellnourished infants in whom adequate abdominal palpation is difficult, or when the obstruction is of long standing and the tumour hes posteriorly), we examine the patient under mild general anæsthesia. The infant suspected of having pyloric stenosis but without palpable tumour is prepared as for surgery by fluid replacement, repair of metabolic alkalosis, and nasogastric suction. General anaesthesia is induced and maintained with halothane 1-2
