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screening and a brief but universal physical examination ofnewborns would be most appropriate for the two former

categories. However, the situation is quite different for neuro-logical and developmental disorders. Often these are not

immediately obvious and do require the passage of time. It isnot easier to detect these before than after 14 months. It is fareasier to note neuromuscular incoordination in the child who istrying to walk or ought to be walking than in one who is not.

I submit that for these problems the 80% level of sensitivity,given by Dr. Richards and Dr. Roberts as " probably theacceptable minimum ", is unrealistic and unnecessary. Amongmiddle-class patients, who are generally quite sensitive to thedevelopment of their children, the parents will usually bringthe child to the attention of the doctor long before any specificremedial action is possible. However, among the less sophisti-cated, among those who might not recognise developmentalabnormality until so late that the child has already been enteredin school and several years of valuable chance of special educa-tion have been lost, the concept of early intensive screening fordevelopmental abnormality seems entirely appropriate.Dr. Richards and Dr. Roberts write: " Drillien found that in

30% of patients with cerebral palsy there had been no obstetricor neonatal complications "; the obverse of this is that 70% ofsuch patients did have something in their history which sug-gested careful and regular follow-up-Dr. Robson makes asimilar point in his letter last week (p. 886).Given the shortage of trained paediatricians (in our own

community they are leaving the practice of paediatrics in

alarming numbers because of the relatively low pay and thevery demanding hours and patient-loads), the suggestion thatspecial attention should not be paid to the groups at highestrisks seems retrograde. In a period of relatively diminishingmedical manpower, we must concentrate our efforts wherethere is greatest need. Some of the details of several proposed"

at risk " registers may be unworkable or inefficient; the con-cept is, on the other hand, essential to the improvement ofmedical services.

DAVID RUSH.

Department of Preventive Medicineand Community Health,University of Rochester,

New York 14620.

DEFECTS DUE TO PRECONCEPTIONAL RUBELLA?

SIR,-In May, 1956, a patient had a typical attack of rubella(during an outbreak in the neighbourhood). In October, 1956,she conceived, and gave birth, in June, 1957, 5 weeks before theexpected date of delivery, to a boy, birthweight 2190 g.Apart from the prematurity, the pregnancy and the labourwere normal, and the baby thrived well.The boy, now aged 10 years, has the following abnormalities:1. Paralysis of the external-rectus muscle and microphthalmos

of the left eye (noticed at birth).2. Partial internal-ear deafness of the right ear (75% reduction of

hearing on audiometric examination), discovered at the age of 10years (the boy had mumps at the age of 6 years, but this usuallygives rise to total deafness of an ear).

3. Minimal cerebral dysfunction (over active, difficulty in concen-tration, impulsive, impatient, temper-tantrums, and calmed by smalldoses of amphetamine). This is improving as he grows older.

4. Defective dental enamel.5. Genu valgum and genu recurvatum.

In view of the recent evidence that the rubella virus remainsviable for many months, or even, as Dr. Menser and herco-authors show (Aug. 19, p. 387), for years after the initialinfection, it seems feasible that the boy was infected in-utero bythe rubella virus acquired by his mother 5 months before hisconception.

It would be interesting to hear of similar cases. Proof of thispossibility would have practical clinical application. In themeantime, I have decided, arbitrarily, that I will advise femalepatients who get rubella in the childbearing age to avoidpregnancy for one year after the infection.

S. BEN-MEIR.

EFFECT OF PENTAGASTRIN AFTER VAGOTOMY

SIR,-In the recent multicentre study (Sept. 9, p. 534), inwhich the stimulus to gastric secretion was pentagastrin givenby continuous intravenous infusion in a dose of 6 g. per kg.per hour, a mean reduction of 62% in the peak acid responsewas demonstrated in patients with proven vagotomies.We have studied the peak acid output in a group of 13

patients (11 men and 2 women) undergoing surgical vagotomyto whom histamine 0-04 mg. per kg. and pentagastrin 6 g.per kg. were given subcutaneously preoperatively and post-operatively. The completeness of vagotomy was confirmedby the Hollander insulin-hypoglycxmia test. The mean peakacid response (in mEq. hydrochloric acid per hour) before andafter vagotomy respectively was 33-4 and 12.5 with histamine,and 30-1 and 11-5 with pentagastrin. Thus there was no

significant difference between the mean peak acid outputusing histamine or pentagastrin either preoperatively or

postoperatively (P>0-20). The mean reduction in peak acidresponse after vagotomy was 62-6% with histamine and61-8% with pentagastrin. The figure for pentagastrin-stimulated secretion after vagotomy is virtually identicalwith that in the multicentre study.These figures indicate that comparable peak acid responses

may be obtained with subcutaneous and intravenous penta-gastrin in vagotomised patients. This observation may beuseful in centres where facilities for constant infusion are notavailable.

We are grateful to Dr. D. J. Fitzgerald (medical department,I.C.I.) for supplies of pentagastrin.

J. M. WILLIAMSONR. HUMEE. M. WEYERS.

Department of Medicine,Southern General Hospital,

Glasgow S.W.1.

MANAGEMENT OF BURNS

SIR,-It has been obvious for some time that the results ofmodern research into the treatment of burns have been

disappointing and that there has been little advance in topicaltreatment since the 1939-45 war. Might it be that much ofthis research is misdirected, and that those responsible forresearch projects are unaware of the true nature of theclinical problems ?

In principle the requirements for satisfactory healing of aburns wound are generally agreed to be as follows:

1. Prevention of fluid-loss from the surface.2. Reduction of inflammation and oedema.3. Primary disinfection.4. Encouragement of the natural separation of sloughs without

putrefaction.5. Concomitant growth of healthy granulation tissue and

epithelium.6. Early restoration of function.7. Atraumatic protective dressings.8. Last, but not least, the prevention of pain and discomfort-

rarely referred to in the published reports.

Hypochlorous-acid (HOCI) solutions, used in correct con-centrations and in adequate amounts, will provide all these

requirements. With the use of the occlusive envelope insteadof painful dressings, most burns can be protected from

infection, or, if already infected, can be disinfected, so thateven well-established pyocyaneus infections can be controlledwithin 24 hours. HOCI is a potent proteolytic agent not onlybecause it combines chemically with protein, but because itexerts a powerful positive chemotaxis.

All sloughs, no matter how deep, can be separated withoutputrefaction within 14 days-painlessly and atraumatically,without anaesthesia or soaking off of dressings. Healthygranulations form during this time, so that grafting may bebegun 14 days after the burn with confidence that infectionwill not supervene.There exists a wide gap in knowledge of the action of

antiseptics, and particularly of HOC1. This can possibly beexplained by the experiments of Fleming and Colebrook, who