872
SIR,-Professor Mills and Dr Harrison (Oct. 1, p. 707), commenting on the paper by Dr Barraclough and his colleagues point out that the published statistics for suicide in Britain show a progressive fall and that the diagnosis depends the interpretation of the events by the coroner. As. the World Health Organisation has indicated1 there is an extraordinary range of suicide-rates, reflecting differences in almost every aspect of reporting, recording, investigating, and adjudicating a possible suicide death, apart from cultural attitudes. In England and Wales, the suicide-rate has fallen over the past fifteen years from 12 per 100 000 to 8 per 100 000, an exception to the experience of most advanced countries. Over this period hospital admissions for attempted suicide have increased. A cause of the fall could include the Samaritans, a change in the age-group involved, different methods used and improved treatment, but, in view of the W.H.O. findings, a change in our adjudicating must be considered. As Watts2 has said: "The Coroner today bends over backwards to avoid the verdict of suicide so that the statistics are an under-estimate of the true state of affairs". It may well be that it is not so much a question of bending backwards, but of swaying to the wind of change in interpreting the law. In recent years the courts have emphasised in effect that, unless a clear intention is expressed, a suicide verdict must not be
on
DEATHS FROM FALLING AT BEACHY HEAD
* Part
returned. In 1968, the Court of Appeal stated that suicide requires an intention to kill oneself, which must be affirmatively proved,3 and in 1970 Lord Parker emphasised that the presumption was always against suicide, which had to be
strictly proved.4 Locally, there is a suicide method which has been unaffected by North Sea gas, prescribing habits, or availability-and which has, in fact, remained largely unaltered for some 80 million years. Details of suicides by jumping from the cliffs of Beachy Head have been described,s and the table shows the total number of deaths in the past ten years and the number where a verdict of suicide was returned. From 1968 to 1974 inclusive, on average suicide verdicts were returned on 67% and for 1975, 1976, and 1977, the average is 20%. The suicide profile of these victims, taking into account general factors6 such as previous attempts, history of mental illness, recent emotional upset, and specifically local factors such as being seen to jump off, leaving belongings on cliff edge or "behaving strangely" on the edge, showed no change over the years. In December, 1974, the Lord Chief Justice quashed a verdict of the coroner in the case of a man who fell from a cliff.7 Lord Widgery commented that, while he was not censuring the coroner and while he accepted that no-one could get to the cliff 1. Suicide and Attempted Suicide Publ. Hlth Pap. W.H.O. 1974, no. 58. 2. Watts, C. A. H. Br. med. J. 1975, iii, 42. 3. re Davis (deceased); (1968) 1 Q.B. p. 82D. 4. R v Cardiff City Coroner ex p Thomas (1970) 1 WLR 1475. 5. Surtees, S. J., Taylor, D. C., Cooper, R. W. Eastbourne med. Gaz. 1976, 22. 6 British Medical Journal, 1975, ii, 525. 7 Daily Telegraph, Dec. 7, 1974.
except by a deliberate act, it did not follow that the deceased got over with the intention of ending his life. Vhen you consider that the deceased had had to climb over a five foot fence to reach the edge and that a nurse had said the victim had threatened to injure himself it is possible to understand how strict the interpretation of the proof of suicide has become. This may well be the correct legal interpretation to follow, but a factor in this reduced suicide-rate locally would appear to be adjudication change, and perhaps this is a factor elsewhere, because other suicide verdicts have also been quashed for similar reasons.
edge
2,
Eastbourne Postgraduate Medical Centre, District General Hospital, Eastbourne BN21 2UD
S.
J. SURTEES
MANAGEMENT OF WHOOPING-COUGH
SIR,-After the unresolved (and unresolvable?) debate on the merits of whooping-cough vaccination, it was good to see some discussion in your columns of the management of the acutal disease, a subject very poorly dealt with in the textbooks. I do not share Barrie’s view’ that whooping-cough in babies is usually a trivial disease, no different from other common respiratory infections, nor do I believe that the notified mortality (2-13 in England and Wales)2 reflects the true situation, quite apart from the long-term morbidity, which these figures do not cover. The effect of antibiotics is fairly well established; infectivity is lowered, and if given before the paroxysmal stage they may mitigate the symptoms.3 Erythromycin appears to be the drug of choice, ampicillin being ineffective, and other drugs more toxic.4,5 I strongly support the view that infant siblings of cases should receive a prophylactic course.6 Trials of steroids have been few but have shown that they may be beneficial,’especially if given early, and a case could be made for giving them to small babies with severe disease. Humidity is important, since secretions are often very viscid. Phenobarbitone may help, though I have not been as impressed by its efficacy as Davis.9 Oxygen has only a minor role since, in the absence of pneumonia, hypoxia is a problem only
during paroxysms. Straightforward so far. But what should one actually do when a baby has a severe paroxysm? Should one immediately attack the child with physiotherapy, or wait on the sidelines for fear that intervention may prolong the spasm? What about suction: when and how often? Some babies are so sensitive that opening the incubator door is enough to set off a frightening spasm, but if secretions are not removed, pneumonia may ensue. When should one intubate? When the pulse-rate falls to 30/min or, prophylactically, after a series of severe paroxysms? A tube may be difficult to remove, particularly if the disease has a week or more to run. Finally, what about cough-suppressants? A search of the literature has failed to reveal any mention of these drugs. which are normally contraindicated in severe respiratory disease, since cough is an important protector of the lungs. But in my experience, morbidity and mortality arise less from pneumonia than from apnoea after a paroxysm, which presumably is the baby carrying on coughing when he has no air left to cough with. Is not such a baby carrying a good thing too far? An epidemic of whooping-cough is expected next year. This 1. Barrie, H. Lancet, 1977, i, 648. 2. Joint Committee on Vaccination and Immunisation, Br. med. J. 1975, iii, 687. 3. M.R.C. Antibiotics Clinical Trials Committee. Lancet, 1953, i, 1109. 4. Bass, J. W., and others, J. Pediatrics, 1969, 75, 768. 5. Bass, J. W. ibid. 1973, 83, 891. 6. Rabo, E. Lancet, 1977, ii, 707. 7. Zoumboulakis, D. and others, Archs Dis. Childh. 1973, 48, 51. 8. Chandra, H. and others, Indian Pœdiat. 1972, 9, 70. 9. Davis, J. A. Br. med. J. 1975, iv, 757.
873 will be a good opportunity for more research into the manageof this unpleasant, and occasionally dangerous, disease.
ment
Department of Pædiatrics, Mary’s General Hospital,
St
STEPHEN WARE
Portsmouth PO3 6AD
FOOD AND MORTALITY IN BELGIUM SIR,-We have several criticisms of the paper by Joossens et al.’ to add to those made by others. 2-6 Comparing consumption data obtained from different sources in different years and employing a calculated "unit of consumption" are both highly questionable, the latter being influenced by such factors as family size and the proportion of people from rural areas. Deaths from non-cardiovascular disease, like "deaths from all causes" were higher in the south of Belgium. The mortality figures (minus those for cancer and accidents) which were used for correlating cardiovascular deaths with butter consumption per province also include deaths from non-cardiovascular causes, which are as high as 33.5% in the north and 39% in the south. The methods used for calculating correlations have been criticised6 but Joossens et al. in addition apparently failed to notice that the result is opposite to that expected if butter consumption were a causal factor in coronary heart-disease. The data on fat consumption, if valid, indicate that the total fat intake in the north is now at a level low enough, in our opinion, conforms with a recommended food pattern. 7,8 From these data we calculate that the intake of saturated fat decreased from 65 to 38 g/day/unit of consumption, whereas the intake of polyunsaturated fats (P.U.F.) increased only from 13 to 16 g/day/unit. This small increase thus has little significance in the doubling of the polyunsaturated/saturated ratio. Neither does it justify speculation about a link between the P.U.F. intake and deaths from cancer. The total consumption of margarine and butter was similar in both parts of Belgium and in each province but saturated fats from other sources must also be taken into account. In the Netherlands, apart from margarine, meat is the main contributor. If butter is replaced by margarine, mortality is unlikely to change because neither total fat consumption nor saturated fat consumption would have changed. In our view a decrease in total and saturated fat consumption is important in the prevention of coronary heart-disease and too much attention has been given to butter consumption compared with other sources of dietary fat. Butter consumption reflects a cultural pattern, but cannot be seen as a primary cause of coronary disease. It would be simple, otherwise, to prove that speaking French in Belgium would cause electrocardiographic disturbances or even myocardial infarctions. The situation in France however is less threatening.2 Netherlands Institute for Ede, Netherlands Dutch Dairy
Dairy Research, H.
DE
WAARD
Bureau,
G. J. HIDDINK
Rijswijk
SIR,-The
paper
predisposing factor
by Joossens
et
al.1
implicating
in coronary disease contained
fallacies. II Joossens
a
butter as a number of
et al. considered eight demographic samples drawn from the Belgian population. In four, family diets were examined (group 1) and in the others, the incidence ofischsmic heart-disease (I.H.D.) among males drawn mainly from the army(group 2) was determined. No evidence that those in
1 Joossens. J V., and others, Lancet, 1977, i, 1069. 2 MacLennan, R., Meyer, F. ibid 1977, ii, 133. 3 Astrup, Pibid. p. 194 4 Segall, JJibid 5. Howard, A N. ibid p 255. 6 Renner, E ibid p 306. 7. Joossens, JJ V, and others Lancet, 1977, i, 1069.
were or had been members of group 1 was offered and the yet dietary habits of the, first group were assumed to apply to the second. (2) Even if this irrelevance is accepted, the "unit of consumption" does not retrieve the situation. The life expectancy of a man is not affected by any predilection his wife may have for buttered buns. (3) The association between the average butter consumption of group 1 and the average I.H.D. incidence of group 2 in nine provinces was offered as evidence that butter increases the risk of coronary disease. However, an association between the mortality-rate and butter consumption by the whole population does not imply that a similar association related to the males within the population. (4) The language difference between the northern (Dutch speaking) and the southern (French speaking) provinces produced two regions which may be genetically distinct. The death-rates per 1000 males were 12-0 in the north and 16.0 in the south which suggests that the northener is more robust than the southerner. Despite this, cancer accounted for 30.6% of all deaths in the north and only 24.8% in the south while coronary attacks accounted for 25.3% and 24.7%, respec-
group 2
tively. (5) A correlation coefficient betwen mean mortality-rates per 1000 males and mean butter consumption per family was calculated for all nine provinces. If regional locations were considered and Fisher’s Z test is applied, we find: South: r = 091;Z= 1.33;f- 2.14, 2 d.f., N.s. (not North: r= 0.03; Z = 0,03; t = 0,04,2 2d.f., N.S. Combined: r 0.75; Z= 0.97; t 2.38,66 d.f., N.S.
significant).
=
=
There is thus no evidence of a significant relationship between the mean consumption of butter in group 1 and mortality in group 2. (6) We are told that some families of genotype N prefer margarine to butter and some families of genotype S prefer butter to margarine; also that some males of genotype N live longer than some males of genotype S. However, no valid conclusion on the effect of diet on mortality can be drawn from these statements because the effect it is desired to show could be confounded by sex and genotype. I find it disturbing that margarine could be associated with increased risk of cancer but I doubt whether the truth can be deduced from data of this sort. Certainly the conclusion that this Belgian study casts doubt on the ethics of campaigns for the promotion of butter consumption cannot be justified. Milk Marketing Board, Thames Ditton, Surrey KT7 OEL
P. D. P. WOOD
THE SHIRODKAR STITCH
SIR,-You ask (Oct. 1, p. 691) for more objective evidence of the value of the Shirodkar stitch in preventing midtrimester abortions and premature delivery. You correctly point out that since this procedure is an established obstetric practice a statistically acceptable trial would be difficult to carry out. We have analysed the results from 100 consecutive cervical inserted in this hospital over a seven-year period. Durthe same time 48 423 babies over 28 weeks’ gestation were delivered. The patients had a history of repeated midtrimester abortions or premature labour for which cervical incompetence seemed the most likely cause. Between them these 100 patients had lost. 287 pregnancies after’the first trimester. Cervical suturing, using the simple technique of cerclage was done betwen the 12th and 14th week of pregnancy, and in every case the membranes were intact. No other efforts to prevent labour, such as prolonged bed rest or sedation, were used. No significant complication occurred. 13 patients subsequently aborted or went into very premature labour. 87 patients went on to complete their pregnancies: in this group there was 1 persutures
ing
SIR,-Professor Mills and Dr Harrison (Oct. 1, p. 707), commenting on the paper by Dr Barraclough and his colleagues point out that the published statistics for suicide in Britain show a progressive fall and that the diagnosis depends the interpretation of the events by the coroner. As. the World Health Organisation has indicated1 there is an extraordinary range of suicide-rates, reflecting differences in almost every aspect of reporting, recording, investigating, and adjudicating a possible suicide death, apart from cultural attitudes. In England and Wales, the suicide-rate has fallen over the past fifteen years from 12 per 100 000 to 8 per 100 000, an exception to the experience of most advanced countries. Over this period hospital admissions for attempted suicide have increased. A cause of the fall could include the Samaritans, a change in the age-group involved, different methods used and improved treatment, but, in view of the W.H.O. findings, a change in our adjudicating must be considered. As Watts2 has said: "The Coroner today bends over backwards to avoid the verdict of suicide so that the statistics are an under-estimate of the true state of affairs". It may well be that it is not so much a question of bending backwards, but of swaying to the wind of change in interpreting the law. In recent years the courts have emphasised in effect that, unless a clear intention is expressed, a suicide verdict must not be
on
DEATHS FROM FALLING AT BEACHY HEAD
* Part
returned. In 1968, the Court of Appeal stated that suicide requires an intention to kill oneself, which must be affirmatively proved,3 and in 1970 Lord Parker emphasised that the presumption was always against suicide, which had to be
strictly proved.4 Locally, there is a suicide method which has been unaffected by North Sea gas, prescribing habits, or availability-and which has, in fact, remained largely unaltered for some 80 million years. Details of suicides by jumping from the cliffs of Beachy Head have been described,s and the table shows the total number of deaths in the past ten years and the number where a verdict of suicide was returned. From 1968 to 1974 inclusive, on average suicide verdicts were returned on 67% and for 1975, 1976, and 1977, the average is 20%. The suicide profile of these victims, taking into account general factors6 such as previous attempts, history of mental illness, recent emotional upset, and specifically local factors such as being seen to jump off, leaving belongings on cliff edge or "behaving strangely" on the edge, showed no change over the years. In December, 1974, the Lord Chief Justice quashed a verdict of the coroner in the case of a man who fell from a cliff.7 Lord Widgery commented that, while he was not censuring the coroner and while he accepted that no-one could get to the cliff 1. Suicide and Attempted Suicide Publ. Hlth Pap. W.H.O. 1974, no. 58. 2. Watts, C. A. H. Br. med. J. 1975, iii, 42. 3. re Davis (deceased); (1968) 1 Q.B. p. 82D. 4. R v Cardiff City Coroner ex p Thomas (1970) 1 WLR 1475. 5. Surtees, S. J., Taylor, D. C., Cooper, R. W. Eastbourne med. Gaz. 1976, 22. 6 British Medical Journal, 1975, ii, 525. 7 Daily Telegraph, Dec. 7, 1974.
except by a deliberate act, it did not follow that the deceased got over with the intention of ending his life. Vhen you consider that the deceased had had to climb over a five foot fence to reach the edge and that a nurse had said the victim had threatened to injure himself it is possible to understand how strict the interpretation of the proof of suicide has become. This may well be the correct legal interpretation to follow, but a factor in this reduced suicide-rate locally would appear to be adjudication change, and perhaps this is a factor elsewhere, because other suicide verdicts have also been quashed for similar reasons.
edge
2,
Eastbourne Postgraduate Medical Centre, District General Hospital, Eastbourne BN21 2UD
S.
J. SURTEES
MANAGEMENT OF WHOOPING-COUGH
SIR,-After the unresolved (and unresolvable?) debate on the merits of whooping-cough vaccination, it was good to see some discussion in your columns of the management of the acutal disease, a subject very poorly dealt with in the textbooks. I do not share Barrie’s view’ that whooping-cough in babies is usually a trivial disease, no different from other common respiratory infections, nor do I believe that the notified mortality (2-13 in England and Wales)2 reflects the true situation, quite apart from the long-term morbidity, which these figures do not cover. The effect of antibiotics is fairly well established; infectivity is lowered, and if given before the paroxysmal stage they may mitigate the symptoms.3 Erythromycin appears to be the drug of choice, ampicillin being ineffective, and other drugs more toxic.4,5 I strongly support the view that infant siblings of cases should receive a prophylactic course.6 Trials of steroids have been few but have shown that they may be beneficial,’especially if given early, and a case could be made for giving them to small babies with severe disease. Humidity is important, since secretions are often very viscid. Phenobarbitone may help, though I have not been as impressed by its efficacy as Davis.9 Oxygen has only a minor role since, in the absence of pneumonia, hypoxia is a problem only
during paroxysms. Straightforward so far. But what should one actually do when a baby has a severe paroxysm? Should one immediately attack the child with physiotherapy, or wait on the sidelines for fear that intervention may prolong the spasm? What about suction: when and how often? Some babies are so sensitive that opening the incubator door is enough to set off a frightening spasm, but if secretions are not removed, pneumonia may ensue. When should one intubate? When the pulse-rate falls to 30/min or, prophylactically, after a series of severe paroxysms? A tube may be difficult to remove, particularly if the disease has a week or more to run. Finally, what about cough-suppressants? A search of the literature has failed to reveal any mention of these drugs. which are normally contraindicated in severe respiratory disease, since cough is an important protector of the lungs. But in my experience, morbidity and mortality arise less from pneumonia than from apnoea after a paroxysm, which presumably is the baby carrying on coughing when he has no air left to cough with. Is not such a baby carrying a good thing too far? An epidemic of whooping-cough is expected next year. This 1. Barrie, H. Lancet, 1977, i, 648. 2. Joint Committee on Vaccination and Immunisation, Br. med. J. 1975, iii, 687. 3. M.R.C. Antibiotics Clinical Trials Committee. Lancet, 1953, i, 1109. 4. Bass, J. W., and others, J. Pediatrics, 1969, 75, 768. 5. Bass, J. W. ibid. 1973, 83, 891. 6. Rabo, E. Lancet, 1977, ii, 707. 7. Zoumboulakis, D. and others, Archs Dis. Childh. 1973, 48, 51. 8. Chandra, H. and others, Indian Pœdiat. 1972, 9, 70. 9. Davis, J. A. Br. med. J. 1975, iv, 757.
873 will be a good opportunity for more research into the manageof this unpleasant, and occasionally dangerous, disease.
ment
Department of Pædiatrics, Mary’s General Hospital,
St
STEPHEN WARE
Portsmouth PO3 6AD
FOOD AND MORTALITY IN BELGIUM SIR,-We have several criticisms of the paper by Joossens et al.’ to add to those made by others. 2-6 Comparing consumption data obtained from different sources in different years and employing a calculated "unit of consumption" are both highly questionable, the latter being influenced by such factors as family size and the proportion of people from rural areas. Deaths from non-cardiovascular disease, like "deaths from all causes" were higher in the south of Belgium. The mortality figures (minus those for cancer and accidents) which were used for correlating cardiovascular deaths with butter consumption per province also include deaths from non-cardiovascular causes, which are as high as 33.5% in the north and 39% in the south. The methods used for calculating correlations have been criticised6 but Joossens et al. in addition apparently failed to notice that the result is opposite to that expected if butter consumption were a causal factor in coronary heart-disease. The data on fat consumption, if valid, indicate that the total fat intake in the north is now at a level low enough, in our opinion, conforms with a recommended food pattern. 7,8 From these data we calculate that the intake of saturated fat decreased from 65 to 38 g/day/unit of consumption, whereas the intake of polyunsaturated fats (P.U.F.) increased only from 13 to 16 g/day/unit. This small increase thus has little significance in the doubling of the polyunsaturated/saturated ratio. Neither does it justify speculation about a link between the P.U.F. intake and deaths from cancer. The total consumption of margarine and butter was similar in both parts of Belgium and in each province but saturated fats from other sources must also be taken into account. In the Netherlands, apart from margarine, meat is the main contributor. If butter is replaced by margarine, mortality is unlikely to change because neither total fat consumption nor saturated fat consumption would have changed. In our view a decrease in total and saturated fat consumption is important in the prevention of coronary heart-disease and too much attention has been given to butter consumption compared with other sources of dietary fat. Butter consumption reflects a cultural pattern, but cannot be seen as a primary cause of coronary disease. It would be simple, otherwise, to prove that speaking French in Belgium would cause electrocardiographic disturbances or even myocardial infarctions. The situation in France however is less threatening.2 Netherlands Institute for Ede, Netherlands Dutch Dairy
Dairy Research, H.
DE
WAARD
Bureau,
G. J. HIDDINK
Rijswijk
SIR,-The
paper
predisposing factor
by Joossens
et
al.1
implicating
in coronary disease contained
fallacies. II Joossens
a
butter as a number of
et al. considered eight demographic samples drawn from the Belgian population. In four, family diets were examined (group 1) and in the others, the incidence ofischsmic heart-disease (I.H.D.) among males drawn mainly from the army(group 2) was determined. No evidence that those in
1 Joossens. J V., and others, Lancet, 1977, i, 1069. 2 MacLennan, R., Meyer, F. ibid 1977, ii, 133. 3 Astrup, Pibid. p. 194 4 Segall, JJibid 5. Howard, A N. ibid p 255. 6 Renner, E ibid p 306. 7. Joossens, JJ V, and others Lancet, 1977, i, 1069.
were or had been members of group 1 was offered and the yet dietary habits of the, first group were assumed to apply to the second. (2) Even if this irrelevance is accepted, the "unit of consumption" does not retrieve the situation. The life expectancy of a man is not affected by any predilection his wife may have for buttered buns. (3) The association between the average butter consumption of group 1 and the average I.H.D. incidence of group 2 in nine provinces was offered as evidence that butter increases the risk of coronary disease. However, an association between the mortality-rate and butter consumption by the whole population does not imply that a similar association related to the males within the population. (4) The language difference between the northern (Dutch speaking) and the southern (French speaking) provinces produced two regions which may be genetically distinct. The death-rates per 1000 males were 12-0 in the north and 16.0 in the south which suggests that the northener is more robust than the southerner. Despite this, cancer accounted for 30.6% of all deaths in the north and only 24.8% in the south while coronary attacks accounted for 25.3% and 24.7%, respec-
group 2
tively. (5) A correlation coefficient betwen mean mortality-rates per 1000 males and mean butter consumption per family was calculated for all nine provinces. If regional locations were considered and Fisher’s Z test is applied, we find: South: r = 091;Z= 1.33;f- 2.14, 2 d.f., N.s. (not North: r= 0.03; Z = 0,03; t = 0,04,2 2d.f., N.S. Combined: r 0.75; Z= 0.97; t 2.38,66 d.f., N.S.
significant).
=
=
There is thus no evidence of a significant relationship between the mean consumption of butter in group 1 and mortality in group 2. (6) We are told that some families of genotype N prefer margarine to butter and some families of genotype S prefer butter to margarine; also that some males of genotype N live longer than some males of genotype S. However, no valid conclusion on the effect of diet on mortality can be drawn from these statements because the effect it is desired to show could be confounded by sex and genotype. I find it disturbing that margarine could be associated with increased risk of cancer but I doubt whether the truth can be deduced from data of this sort. Certainly the conclusion that this Belgian study casts doubt on the ethics of campaigns for the promotion of butter consumption cannot be justified. Milk Marketing Board, Thames Ditton, Surrey KT7 OEL
P. D. P. WOOD
THE SHIRODKAR STITCH
SIR,-You ask (Oct. 1, p. 691) for more objective evidence of the value of the Shirodkar stitch in preventing midtrimester abortions and premature delivery. You correctly point out that since this procedure is an established obstetric practice a statistically acceptable trial would be difficult to carry out. We have analysed the results from 100 consecutive cervical inserted in this hospital over a seven-year period. Durthe same time 48 423 babies over 28 weeks’ gestation were delivered. The patients had a history of repeated midtrimester abortions or premature labour for which cervical incompetence seemed the most likely cause. Between them these 100 patients had lost. 287 pregnancies after’the first trimester. Cervical suturing, using the simple technique of cerclage was done betwen the 12th and 14th week of pregnancy, and in every case the membranes were intact. No other efforts to prevent labour, such as prolonged bed rest or sedation, were used. No significant complication occurred. 13 patients subsequently aborted or went into very premature labour. 87 patients went on to complete their pregnancies: in this group there was 1 persutures
ing
