147 PAIN AFTER HEAD INJURY SIR,-Dr. Ebbetts (Jan. 6, p. 46) writes: it seems fantastic that Mr. Wilson, in his article last week (p. 1391), should assume that injuries to the head sufficient to cause skull fracture are not associated with cervical-joint injury." It is not clear whether he uses " fantastic " in its literal sense (" existing only in imagination ") or pejoratively (" extravagantly fanciful, capricious; eccentric, quaint, or grotesque in conception ").1 The lesions to which I draw attention in my open-ended proposal of a possible role of posterior-rootganglion haemorrhages in neck pain after head injury are not imaginary, nor is the suggestion of their relevance in explaining a most unusual sensory disturbance beyond the bounds of reasonable conjecture. Dr. Ebbetts’ more orthodox explanation does not fit the observed clinical facts in the patients I described. Rereading their case-records should persuade him that none of them showed the type of segmental pain, described in softtissue neck injuries by Brain and Wilkinson2 and reproduced experimentally by Inman and Saunders,3 which he probably rightly supposes to originate reflexly from the joints and related structures of the vertebral arches. The liability of cervical roots and root-sleeves to angular and torsional deformation has been well illustrated.4 Violent movements of this kind at the moment of impact to the head may result in small hxmorrhages and axonal disturbances in the region of the root ganglia. Possible axonal mechanisms for hyperalgesia in peripheral neuropathy have been discussed.5 London S.E.5. P. J. E. WILSON. "
INSULIN RESPONSE TO GLUCAGON SIR,-Dr. Milunsky and his co-authors (Nov. 18, p. 1093) obtained low insulin responses after glucagon in children with Down’s syndrome, and mentally subnormal and normal children, and concluded that there is " decreased insulin secretion in response to both natural and pharmacological agents in children ". Our findings in children of 4-11 years do not support this view. Glucose was given orally (2 g. per kg.), and tolbutamide (25 mg. per kg.) and glucagon (20 !J.g. MEAN
CHILDREN AFTER GLUCOSE
AND TOLBUTAMIDE AND GLUCAGON
It is important in childhood to determine the blood-levels of non-esterified fatty acids and ketone bodies during every determination of the pancreatic-(3-cell function, in order to verify the true diminution of insulin secretion. These results
by G. C.
University Paediatric Clinic, Milan. Children’s
Hospital of Pittsburgh, Pittsburgh, Pennsylvania 15213.
GIUSEPPE CHIUMELLO MARIA DEL GUERCIO.
A SPECIAL FLUORIDATED SCHOOL MILK? to the fluoridation of public watersupplies are more than the five listed by Dr. Davis last week (p. 93). The great variability of water-consumption amongst children is one: some children consume large quantities of a
public water-supply, others substitute milk or pop " drinks. Tea contains a relatively high concentration of fluoride, and if made with fluoridated water of course it contains more; Sir Norman Wright1 found that half the 13,317 Scottish schoolchildren he investigated took tea three or more times a day whereas some drank milk at meal-times instead, so this is another cause of variability. Dr. Davis does not mention that the fluoridation of milk for children has not only been discussed for at least fifteen years but has also been investigated. Ziegler,2who also studied fluoridated table-salt, found a favourable effect on dental caries. So did Rusoff and his colleagues3 in a trial on schoolchildren of a daily half-pint of milk containing 1 mg. of fluoride. Ericsson,4using radioactive fluoride with rats, investigated the availability in milk. Other methods of administering fluoride to children if the parents wish, without violating the liberty of the individual, have been tested: these include table-salt (extensively used in Switzerland as well as being tested by W.H.O. in Colombia), salt used in baking bread (being tried in Holland), various cereals, and sweets. Egeconsidered that in Denmark consumption of cereals varied less than that of water. If the main cause of dental caries is the ingestion of refined carbohydrate, particularly sticky sweets, and if fluoride delays dental caries, perhaps (as Jenkins 6 suggested) by a bacteriostatic action in the mouth, then the compulsory fluoridation of sweets is logical. No-one would be forced to eat them, the dose of the prophylactic agent would be proportional to that of the noxious agent, and a child would be sick from a surfeit of sweets before obtaining a toxic dose of fluoride. HUGH SINCLAIR. Oxford.
FŒTAL BLOOD-GLUCOSE LEVEL
SIR,-There is evidence that in the sheep, rhesus monkey, and rabbit, the fcetal blood-glucose concentration is normally
kg.) intravenously. The insulin was measured by radioimmunoassay on heparinised plasma(see table). One reason for our different findings could be the smaller number of children examined by Dr. Milunsky and his colleagues; a second reason could be the great tendency of children to get hyperketonasmia.’ per
1. Shorter Oxford English Dictionary; p. 675. London, 1947. 2. Brain, Lord, Wilkinson, M. (editors) in Cervical Spondylosis and other Disorders of the Cervical Spine; p. 125. London, 1967. 3. Inman, V. T., Saunders, J. B. de C. M. J. nerv. ment. Dis. 1944, 99, 660. 4. Bowden, R. E. M., Sajida, A., Gooding, R. M. in Cervical Spondylosis and other Disorders of the Cervical Spine (edited by Lord Brain and M. Wilkinson); p. 54. London, 1967. 5. Wortis, H., Stein, M. H., Jolliffe, N. Archs intern. Med. 1942, 69, 222.
Bigelow, N., Harrison, I., Goodell, H., Wolff, H. G. J. clin. Invest. 1945, 24, 503. 6. Hales, C. N., Randle, P. J. Lancet, 1963, i, 200. 7. Schwarz Tiene, E., Chiumello, G., Del Guericio, M. J., Gardoni, L., Ghidoni, A., Bidone, G. Helv. pœdiat. Acta, 1967, 22, 230.
about half the maternal level until term but increases in the presence of hypoxia.’ It has been suggested that the same may apply in the human foetus and that the higher glucose levels at birth result from stress and hypoxia during delivery. The postpartum fall in glucose may therefore merely indicate a reversion to the intrauterine level.8 We have recently had the opportunity of measuring the foetal blood-glucose level before the onset of labour. The membranes of a patient 24 weeks pregnant spontaneously ruptured, and a hand presented through the cervix. The patient was not in labour and was given a mild barbiturate sedative. The foetal heart-rate was normal and there was no clinical evidence of hypoxia. Capillary blood from the foetal Wright, N. C. Bull. Hannah Dairy Res. Inst. 1936, no. 7. Ziegler, E. Schweiz. med. Wschr. 1965, 95, 453. Rusoff, L. L., Konikoff, B. S., Frye, J. B., Johnston, J. E., Frye, W. W. Am. J. clin. Nutr. 1962, 11, 94. 4. Ericsson, Y. Acta Odont. scand. 1958, 16, 51. 5. Ege, R. Tandlœgebladet, 1961, 65, 445. 6. Jenkins, G. N. The prevention of dental caries. Newcastle upon Tyne, 1. 2. 3.
1965. 7. 8.
Shelley, H. J., Neligan, G. A. Br. med. Bull. 1966, 22, Davis, J. A. Pediatrics, Springfield, 1967, 39, 585.