for Sudden Infant Death Syndrome
Legislation
To the Editor.\p=m-\Tocomment on Dr. Lewak's letter (230:671, 1974), I find that California is not the first state to introduce legislation for the management of the sudden infant death syndrome (SIDS). Washington has provided for autopsies on children under 3 years of age since 1963 (RCW 68.08.100). Massachusetts was the first to budget state funding for autopsies on children under 2 years of age (Chapter 1072 of the Acts of 1973). In Michigan, Rep James Damman introduced HB 5505 in 1973 to provide for payment for autopsies on SIDS infants and counseling of parents.
The National Foundation for Sudden Infant Deaths, Inc., which Dr. Lewak represents in Northern California, has publicized several instances of police mismanagement of SIDS, such as that noted in Elsinore. Such occurrences are rare and hopefully not frequent in the context of about 15,000 SIDS cases annually. Realistically, however, if Dr. Lewak should happen to be a medical examiner or investigator, he would realize that there are occasional "grey zones" that are most difficult to resolve.1 As Deputy Medical Examiner of Wayne County in Detroit, I have been studying the pathology and epi¬ demiology of SIDS for the past 15 years.2 I have also been concerned with the grief and counseling of the bereaved parents and assisted them in founding the Michigan Association for Sudden Infant Death Study, Inc., in 1965.3 I have found that working closely with the police and providing educational material at all levels helped to prevent improper and pre¬ mature apprehension of bereaved parents. Recently, the American Academy of Forensic Sciences has drafted a uniform procedural guide for the management of SIDS by med¬ ical examiners and law enforcement agencies over the nation. I found Dr. Lewak's letter, captioned "Mythology and SIDS" (N Engl J Med 291:739, 1974), most pertiEdited
by John D. Archer, MD, Senior Editor.
nent, but I do not agree that SIDS is neither preventable nor predictable, nor that the only symptom is death. There are certain indicators and highrisk factors attributable to the mother prenatally, and found postnatally in the infant. Among these are immaturity and low birth weight, high cohort number, environmental and socioeconomic factors affecting the mother, juvenile motherhood, and high-risk pregnancy. The epidemicity and seasonal periodicity of SIDS cor¬ responds to the incidence of respira¬ tory or viral infection in the general population. Research is continuing on this serious disease entity. Clara Raven, MD Detroit
1. Raven C:
Why an obligatory autopsy in the sudden infant death syndrome. Forensic Sci 2:387, 1973. 2. Raven C: Sudden infant death syndrome: An epidemiologic study. J Am Med Wom Assoc 20:124, 1974. 3. Raven C: Michigan Association for Sudden Infant Death Study. J Forensic Med 16:120, 1969.
Pitfalls in Diagnosis To the Editor.\p=m-\"Toerr in the diagnosis of a relievable disorder is a tragedy," is Dr. Aring's initial statement in his editorial comment (229:1879, 1974) on recent articles1-3 emphasizing the pitfalls in diagnosis of lesions about the junction of medulla and spinal cord. Dr. Boshes, discussing a case in The Journal
(229:1518, 1974) of
a
middle-aged
with chronic neurologic findings, failed to mention a treatable lesion at the foramen magnum in his woman
differential diagnosis. The limited clinical description indicated no cranial nerve abnormality except a vague history of visual disturbance "ten years ago, the details of which she could not recall." The chorioretinitis described could be responsible. All the other neurological findings of tremor, weakness, pyramidal signs, unilateral proprioceptive loss, and neurogenic bladder could result from a high spinal lesion. The weight loss, fever, anemia, and other constitutional symptoms may be the sequelae of chronic urinary infection; the hemoglobin value rose and hydronephrosis cleared after uro-
logical care. A follow-up report indicated that
Downloaded From: http://jama.jamanetwork.com/ by a Carleton University User on 05/12/2015
a
foramen magnum lesion was looked for with a cervical myelogram; how¬ ever, recent articles13 indicate the frequency of misdiagnosis of high spinal cord lesions by failure to per¬ form a complete myelogram, which should include supine views and fill¬ ing of the basilar cisterns. Harvey J. Blumenthal, MD
Tulsa, Okla
1. Howe JR, Taren JA: Foramen magnum tumors: Pit-
falls in diagnosis. JAMA 225:1061-1066, 1973. 2. Missed foramen magnum tumours, editorial. Lancet
2:1482,
1973. 3. Bull J: Missed foramen magnum tumours. Lancet
1:91, 1974.
Dark-Field Examination In Early Primary Syphilis To the Editor.\p=m-\Regardingthe article Duncan et al (228:859, 1974), I want to emphasize that specific and nonspecific serological tests for syphilis are not reactive in early primary lesions. In the Los Angeles City Health Department, I treated a male prostitute who was keenly aware of the great hazard connected with his occupation. He appeared in the venereal clinic of the City Health Department on three different occasions, many months apart, each time having a minimal, nonindurated erosion on his penis. Each time, Treponema pallidum was present in the serum. He never developed a reactive serological test, either specific or nonspecific. There is no clinical or serological evidence that this patient ever had a syphilitic infection, although he had three of them, all verified by the presence of T pallidum in his lesions. There is no substitute for darkfield examination in very early pri-
by
mary
syphilis.
Max Popper, MD
Los
Angeles
To the Editor.\p=m-\Wedid not intend to detract from the importance of the dark-field examination in the diagnosis of primary syphilis. Seronegative primary syphilis is well known. The point we wish to make is that by the time a patient comes for treatment, the vast majority (91%) will have seropositive results with the FTA-ABS test. Two of the six patients had dark-field-positive, FTA-ABS-negative results two and four months later, respectively, and remained seronegative to both the VDRL and FTA-ABS tests. Two of the patients in our study stated that their lesions had been present only three days: in one, the
Legislation
To the Editor.\p=m-\Tocomment on Dr. Lewak's letter (230:671, 1974), I find that California is not the first state to introduce legislation for the management of the sudden infant death syndrome (SIDS). Washington has provided for autopsies on children under 3 years of age since 1963 (RCW 68.08.100). Massachusetts was the first to budget state funding for autopsies on children under 2 years of age (Chapter 1072 of the Acts of 1973). In Michigan, Rep James Damman introduced HB 5505 in 1973 to provide for payment for autopsies on SIDS infants and counseling of parents.
The National Foundation for Sudden Infant Deaths, Inc., which Dr. Lewak represents in Northern California, has publicized several instances of police mismanagement of SIDS, such as that noted in Elsinore. Such occurrences are rare and hopefully not frequent in the context of about 15,000 SIDS cases annually. Realistically, however, if Dr. Lewak should happen to be a medical examiner or investigator, he would realize that there are occasional "grey zones" that are most difficult to resolve.1 As Deputy Medical Examiner of Wayne County in Detroit, I have been studying the pathology and epi¬ demiology of SIDS for the past 15 years.2 I have also been concerned with the grief and counseling of the bereaved parents and assisted them in founding the Michigan Association for Sudden Infant Death Study, Inc., in 1965.3 I have found that working closely with the police and providing educational material at all levels helped to prevent improper and pre¬ mature apprehension of bereaved parents. Recently, the American Academy of Forensic Sciences has drafted a uniform procedural guide for the management of SIDS by med¬ ical examiners and law enforcement agencies over the nation. I found Dr. Lewak's letter, captioned "Mythology and SIDS" (N Engl J Med 291:739, 1974), most pertiEdited
by John D. Archer, MD, Senior Editor.
nent, but I do not agree that SIDS is neither preventable nor predictable, nor that the only symptom is death. There are certain indicators and highrisk factors attributable to the mother prenatally, and found postnatally in the infant. Among these are immaturity and low birth weight, high cohort number, environmental and socioeconomic factors affecting the mother, juvenile motherhood, and high-risk pregnancy. The epidemicity and seasonal periodicity of SIDS cor¬ responds to the incidence of respira¬ tory or viral infection in the general population. Research is continuing on this serious disease entity. Clara Raven, MD Detroit
1. Raven C:
Why an obligatory autopsy in the sudden infant death syndrome. Forensic Sci 2:387, 1973. 2. Raven C: Sudden infant death syndrome: An epidemiologic study. J Am Med Wom Assoc 20:124, 1974. 3. Raven C: Michigan Association for Sudden Infant Death Study. J Forensic Med 16:120, 1969.
Pitfalls in Diagnosis To the Editor.\p=m-\"Toerr in the diagnosis of a relievable disorder is a tragedy," is Dr. Aring's initial statement in his editorial comment (229:1879, 1974) on recent articles1-3 emphasizing the pitfalls in diagnosis of lesions about the junction of medulla and spinal cord. Dr. Boshes, discussing a case in The Journal
(229:1518, 1974) of
a
middle-aged
with chronic neurologic findings, failed to mention a treatable lesion at the foramen magnum in his woman
differential diagnosis. The limited clinical description indicated no cranial nerve abnormality except a vague history of visual disturbance "ten years ago, the details of which she could not recall." The chorioretinitis described could be responsible. All the other neurological findings of tremor, weakness, pyramidal signs, unilateral proprioceptive loss, and neurogenic bladder could result from a high spinal lesion. The weight loss, fever, anemia, and other constitutional symptoms may be the sequelae of chronic urinary infection; the hemoglobin value rose and hydronephrosis cleared after uro-
logical care. A follow-up report indicated that
Downloaded From: http://jama.jamanetwork.com/ by a Carleton University User on 05/12/2015
a
foramen magnum lesion was looked for with a cervical myelogram; how¬ ever, recent articles13 indicate the frequency of misdiagnosis of high spinal cord lesions by failure to per¬ form a complete myelogram, which should include supine views and fill¬ ing of the basilar cisterns. Harvey J. Blumenthal, MD
Tulsa, Okla
1. Howe JR, Taren JA: Foramen magnum tumors: Pit-
falls in diagnosis. JAMA 225:1061-1066, 1973. 2. Missed foramen magnum tumours, editorial. Lancet
2:1482,
1973. 3. Bull J: Missed foramen magnum tumours. Lancet
1:91, 1974.
Dark-Field Examination In Early Primary Syphilis To the Editor.\p=m-\Regardingthe article Duncan et al (228:859, 1974), I want to emphasize that specific and nonspecific serological tests for syphilis are not reactive in early primary lesions. In the Los Angeles City Health Department, I treated a male prostitute who was keenly aware of the great hazard connected with his occupation. He appeared in the venereal clinic of the City Health Department on three different occasions, many months apart, each time having a minimal, nonindurated erosion on his penis. Each time, Treponema pallidum was present in the serum. He never developed a reactive serological test, either specific or nonspecific. There is no clinical or serological evidence that this patient ever had a syphilitic infection, although he had three of them, all verified by the presence of T pallidum in his lesions. There is no substitute for darkfield examination in very early pri-
by
mary
syphilis.
Max Popper, MD
Los
Angeles
To the Editor.\p=m-\Wedid not intend to detract from the importance of the dark-field examination in the diagnosis of primary syphilis. Seronegative primary syphilis is well known. The point we wish to make is that by the time a patient comes for treatment, the vast majority (91%) will have seropositive results with the FTA-ABS test. Two of the six patients had dark-field-positive, FTA-ABS-negative results two and four months later, respectively, and remained seronegative to both the VDRL and FTA-ABS tests. Two of the patients in our study stated that their lesions had been present only three days: in one, the
