956

(unnecessary abstract adjectival- phrase). He has madean instructive list of overworked words that are often

wrongly used and he gives their alternatives. Onewould like to see a copy of his readable and oftenhumorous-guide on the desk of every official drafting theregulations for the National Health Service. Judging bythe pensions regulations, the lessons of Plain Words haveyet to be learnt in some departments.

INFANTILE METHÆMOGLOBINÆMIA FROMDRINKING-WATER

CYANOSIS is usually produced by reduced haemoglobinin the subpapillary venous plexuses of the skin,l butwhen it occurs without cardiac or pulmonary diseasethe presence of methæmoglobin or sulphaemoglobin inthe blood must be considered. Since 1945 reports havebeen appearing in the North American p2ediatric andpublic-health journals of a cyanotic syndrome in infantsdue to methaemoglobinsemia. This condition is caused

by the ingestion of water derived from rural wells andcontaining more than 10-20 parts per million of nitrateions, a concentration which Comly 2 looks upon as themaximum for waters which can safely be used forinfant feeding. The nitrate ion is transformed by intes-tinal bacteria into nitrite and this is absorbed andconverts some of the circulating haemoglobin into met-haemoglobin. The nitrates which find their wayinto thewell water are formed by the action of soil bacteria onnitrogen compounds present in fertile humus. The wellsare usually rather shallow and inefficiently lined. Waterscontaining large amounts of nitrate are reported byWeart 3 from various areas of the United States, Canada,England, and Belgium, and Weart has found no correla-tion between the nitrate content of well waters and theircontamination with coliform bacteria.That nitrates can be responsible for methaemoglobin-

semia has been known since the introduction of bismuth subnitrate in radiology. Death has been reported 4 after

the administration of bismuth subnitrate for the treat-ment of diarrhoea in a young infant. The nitrates sharetheir property of the intracorpuscular production of

methæmoglobin with coal-tar derivatives, such as are

used in the manufacture of aniline dyes and explosives,and with various drugs such as acetanilide, antipyrin,phenacetin, potassium chlorate, and sulphonamides.Extracorpuscular methæmoglobinæmia is found in

phenylhydrazine poisoning and in severe infections

(01. welchii). Some of these drugs may cause sulphaemo-globin2emia if an excess of sulphide is present in the

gastro-intestinal tract. In " enterogenous cyanosis " the

abnormal pigment is found in the red blood-cells even ifno drug has been taken.5 It is suggested that this condi-tion is due to excessive nitrate production in the gastro-intestinal tract. There are a few cases on record of

idiopathic familial methæmoglobinæmia with cyanosis,‘

possibly due to a congenital metabolic error 6; thesecases respond to large doses of ascorbic acid by mouth.

Nitrate methæmoglobinæmia is much more common ininfants than in adults. Of the various possible reasonsfor this, the relatively large intake of water in infancyis probably the most important ; others are the presenceof smaller amounts of oxidisable haemoglobin in theinfant’s blood ; the more ready absorption of nitrites inthe infant’s gut and possibly a larger formation ofnitrites due to differences in bacterial flora ; and poorelimination by the immature infantile kidney. Ascorbicacid in the blood may counteract the action of nitriteson haemoglobin, and depletion of ascorbic acid may1. Lancet, 1947, ii, 431. 2. Comly, H. H. J. Amer. med. Ass., 1945, 129, 112.3. Weart, J. G. Paper presented at the American Chemical Society

meeting of April 19, 1948. 4. Roe, H. E. J. Amer. med. Ass. 1933, 101, 352.5. Stokvis, B. J. Ned. Tijdschr. Geneesk. 1902, 2, 678.6. Denny J., Murdoch, E. T., Rogan, J. J. Brit. med. J. 1943, i, 721.7. Carnrick, M., Polis, B. D., Klein, T. Arch. intern. Med. 1946, 78, 296.

account for the rapid development of cyanosis after aninfant has been taking a high nitrate water for some time.The clinical picture is one of cyanosis and occasionaldrowsiness, often with gastro-intestinal disturbances ;the condition may be fatal in consequence of anoxæmia.In the State of Illinois Weart has learnt of 33 cases ofnitrate cyanosis in the last year, with 5 deaths. Thesymptoms are said to be quickly relieved by the intra-venous administration of methylene-blue (1-2 mg. perkg. body-weight) and exclusion from the diet of the

offending water, so presumably the condition is onlydangerous if it is unsuspected. -

THE BIRTHDAY HONOURS

THE first name in the list of honours gazetted lastweek is that of Sir Alfred Webb-Johnson, who is createda baron. His many friends will be happy that his work isthus recognised, and the profession as a whole will beglad to have another able representative in the Houseof Lords. It cannot have escaped notice that Sir Alfredis a specialist in restoring vigour to ancient institutions :he is largely responsible for the new Middlesex Hospital,and under his presidency in the difficult years since 1941the Royal College of Surgeons has become once more agreat and developing centre of teaching, full of activityand hope. The president of a sister college is alsohonoured, and much pleasure will be given to his

colleagues by the knighthood now bestowed on Mr.William Gilliatt, obstetric and gynaecological surgeonto King’s College Hospital. Air Vice-Marshal A. F.Rook is promoted K.B.E. for his distinguished service asconsultant in medicine to the Royal Air Force, and thenew knights also include Mr. J. N. Morris, F.R.A.C.S.,Dr. D. T. Rocyn-Jones, formerly medical officer ofhealth for Monmouthshire, and, outside the nominalconfines of the medical profession, Mr. Charles Harington,D.SC., F.R.s., director of the National Institute of MedicalResearch. To these and many others mentioned onanother page we offer warm congratulations.

A MONOPOLY ?

IN a letter this week Mr. E. R. Desoutter, on behalfof the Surgical Instrument Manufacturers’ Association,calls attention to the decision that in the NationalHealth Service artificial limbs will be supplied onlythrough the Ministry of Pensions, which will obtainthem all from two contractors. This means, he says,that most of the private firms making artificial limbsare threatened with extinction ; and it has alreadybeen announced that his own firm, Desoutter Bros.Ltd., has been obliged to discontinue this work. In

Tuesday’s Times, Prof. H. J. Seddon, F.R.c.s., recallsthe departmental committee’s recommendation that".no action shall be taken by the Government whichwould have the effect of gradually forcing out of businessthose firms which do not supply the Government."He appears to be right in saying that " unless the presentplan is changed an almost complete and a very unhealthymonopoly will be created."

SPENS REPORT AND REPRESENTATION OFSPECIALISTS

A MEETING held on June 14 at the Royal College ofPhysicians was attended by 59 consultants andspecialists, including representatives of the three RoyalColleges, the Scottish Medical Corporations, all the

specialties, and the Provincial Teaching HospitalsAssociation. The following resolutions were passedunanimously :

(i) This meeting approves in principle the Spens report,recommends its adoption, and hopes the Governmentwill implement it.

(ii) This committee should continue in existence in orderto consider matters which concern consultants andspecialists.