ANNOTATIONS

and preretmal haemorrhages are an important diagnostic sign of subdural haematorna : ultimately they are present in nearly 00 per cent of these infants, and although some develop under observation the majority k n o t a b l y a direct result of violence. The clinical diag- nosis is clinched by finding fluid of any sort in excess of a millilitre or two on careful sub- dural puncture. Thereafter management is undertaken jointly with a neurosurgical colleague.

It is difficult to believe the statement in standard works of reference that long-bone fractures just happen to accompany subdural haematoma in infancy, or that some physicians have attributed this lesion to scurvy or some ill-defined blood dyscrasia, when adequate laboratory proof was not forthcoming. Trauma may produce subdural haematoma in infancy; when battered infants come to the doctor a deliberate search must be made for this important treatable complication.

N. J. O’DOHERTY

1. N.S.P.C.C. Annual Report 1962-3. 2. Kempe, C. H., Silverman, F. N., Stele, B. F., Droegemueller, W., Silver, H. K. (1962) ‘The battered child

3. Gril€iths, D. Ll., Moynihan, F. J. (1963) ‘Multiple epiphyseal injuries in babies (“battered baby” syn- syndrome.’ J. Amer. med. Ass., 181,17.

drome).’ Brit. med. J., ii, 1558.

INFANT FEEDING IN UNDER-DEVELOPED COUNTRIES THERE is one aspect of infant feeding in the world today to which too little attention seems to be paid. Leading members of the medical profession in Britain and the U.S.A. still do not seem to realise to what an extent they influence medical teaching in under-developed countries, even in countries such as Syria and Turkey which have no special past or present connection with Britain in the way that Iraq and Egypt have. The thought and teaching of these doctors is still concentrated almost entirely on the problems current in Europe and the U.S.A., with only a perfunctory gesture towards the millions outside.

One of the aspects in which this is clearly shown is in the question of bottle-feeding in under-developed countries. In Britain there is a very lax attitude towards this question, and the choice is made according to the mother’s convenience or whim, only a minority of children being breast-fed. Paediatricians do not oppose this attitude very strongly. As a result, doctors in under-developed countries, whether trained there or in Britain or the U.S.A., judge the question of bottle versus breast feeding by the same criteria.

In bottle-feeding it is rare to find a British or American woman who does not make an efficient attempt to sterilise the milk and the bottle, whereas in the rural areas of under- developed countries it is a rarity to find a woman who does so. They draw their water from grossly polluted wells or streams in areas where typhoid and bacillary and amoebic dysentery are endemic; they may or may not boil the water; they rarely boil the bottle or teat or even wash it properly. The rest of the bottle of milk, if not finished by the baby at the time, may be left standing for a few hours in a room temperature of 25” to 30” C, an excellent culture medium. The mothers do not understand anything at all about germs, never having heard of them. Few families can afford to feed a baby on imported powdered milks. The milk itself is possibly black-market skimmed milk powder. They make it up according to what they can afford, not according to any formula. The consequences are appalling.

Yet these are countries where 10 or 20 years ago every woman would have breast-fed her baby without a second thought, most of them very successfully (at least until four or five months, when their failure to introduce other foods would begin to tell). Now, on the other

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hand, the very mothers who most wish to do their best for their children are filled with doubt as to whether their breast milk is adequate, and they know quite well that European women bottle-feed their babies. In this change they are regrettably not discouraged by their doctors; they are even encouraged.

It seems reasonable to say that in the past 10 to 20 years many thousands of lives have been lost in under-developed countries from this cause, and unless there is a change hundreds of thousands more will be lost until the same standards of hygiene obtain there as in Europe and the U.S.A. This despite the advice and experience of those in the field (see, for example, Jelliffel and TroweIP).

It would be most helpful if paediatricians in this country, when discussing the pros and cons of breast-feeding with any audience or readership which could include doctors or health workers in under-developed countries, would add most emphatically that where there is illiteracy, ignorance of hygiene, poverty and poor water supplies, bottle feeding should only be considered as absolutely the very last resort, to be adopted only in desperate cases when all possible steps to maintain and increase lactation, by treating intercurrent infections, increasing leisure and improving diet, and by reassurance, have been taken and have failed, and after every practicable method of supplementary and complementary feeding has been tried.

ROBERT COOK

1. Jelliffe, D. B. (1955) Infant Nutrition in the Tropics and Subtropics. Geneva: W.H.O. 2. Trowell. H. C. (1958) ‘Feeding of infants and children.’ I n Diseases of Children in the Tropics and Sub-

tropics. London: Edward Arnold.

TREATMENT OF MUSCULAR DYSTROPHY IN the past many drugs, including glycine, vitamin E and its analogues and mixed amino- acids, have been used in the treatment of muscular dystrophy, only to be discarded as ineffective after a lengthy clinical trial. Recently DOWBEN~ showed that anabolic steroids could prolong the lives of dystrophic mice of the Bar Harbor strain, and it therefore seemed reasonable to use these drugs in dystrophic patients. DOWFJEN and PERLSTEIN~ in 1961 reported an attempted double-blind controlled trial of norethandrolone in 52 patients with muscular dystrophy. There were toxic side-effects in 7 cases and none of the patients showed any significant improvement in muscle function. More recently, however, DOWBEN3 has given 1-methyl-D1-androstenolone acetate to 37 patients with muscular dystrophy, of whom 19 were suffering from the Duchenne (pseudohypertrophic) variety, 3 from the limb-girdle variety, 8 from facioscapulohumeral dystrophy and 7 from dystrophia m yotonica. Treat- ment was continued for 5-19 months; muscle strength was carefully tested before treatment and at regular intervals thereafter; there were no controls. After 6-8 weeks of treatment, 0.01 mg. of digitoxin per kg. body-weight per week was added in divided doses. There was claimed to be an undoubted increase in muscular strength in 8 patients, including 7 with facioscapulohumeral muscular dystrophy; 3 with the Duchenne type showed progressive deterioration, while the remaining patients were unchanged. The author concluded that his results were encouraging but that treatment should be evaluated by a double-blind trial.

A carefully controlled, double-blind trial of methandrostenolone and nandrolone decanoate, which are pharmacologically related to these steriods, in 40 cases of muscular dystrophy has been reported by BARWICK, NEWELL and WALT ON^. The duration of this trial was only six months, but there was no significant difference in the results obtained with

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