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obtained also by direct cardiac puncture or from parenchy-mal organs. During the third trimester of pregnancy, and inbabies born at term, an adequate quantity of blood (8-10 ml.)for the macromethod may be obtained easily from theumbilical cord directly after delivery.

Cytogenetic analysis is warranted if congenital mal-formation or intrauterine retardation is detected or sus-pected. In fetuses without signs of life, postmortemlymphocyte culture is attempted.12-14 The standard 72-hourculture is thus possible, as opposed to long-term tissueculture which may result in chromosome aberrations.We believe our method is suitable for cytogenetic

screening of the newborn as well.

Z. PAPPS. GARDÓ

Department of Obstetrics and Gynæcology,University Medical School,

Debrecen, Hungary.

RELATIONSHIP OF DIABETIC RETINOPATHY

TO BLOOD-SUGAR

Sir wish to comment on the conclusion of Dr. Adnittand Mrs. Taylor (March 28, p. 652) that progression ofdiabetic retinopathy is unrelated to mean clinic blood-sugar.This is based on the results in 21 patients who were askedto take no food for 2 hours before attending the clinic forblood-sugar tests-i.e., the patients were at least 2 hourspostprandial, but they may have been 6, 8, or 12 hourspostprandial. Since blood-sugars in diabetic patientsfluctuate greatly, depending on the time, type, and quantityof the last meal, the assumption that the clinic blood-sugar(as specified above) is the best available index of glycaemiais not justifiable. The varying ages and durations of diabetesamong the small number of patients of Dr. Adnitt and Mrs.Taylor also reflect on the reliability of the data.

MEAN FASTING-BLOOD-SUGAR LEVELS AND SEVERITY OF RETINOPATHY

IN 324 DIABETIC PATIENTS

* Fundi not seen in 8 cases.

In a retrospective study based on 8924 clinic fasting-blood-sugar measurements in 324 long-term diabetic

patients (during their entire follow-up at the MontrealGeneral Hospital), we 15 found an almost linear correlationbetween severity of retinopathy at the time of the surveyand mean blood-sugar levels. Our data (summarised in theaccompanying table) are not directly comparable with thoseof Dr. Adnitt and Mrs. Taylor since, looking at the patients’eyes at an end-point time, we could not comment onprogression of the disease, but obviously the conclusions ofthe two studies are different. Though prospective studiesare usually statistically superior to retrospective ones, thisadvantage of their study over ours may be offset by thedifficulty of interpreting postprandial blood-sugars indiabetic patients unless the criteria are rigorouslystandardised.

A. J. SZABO.

Department of Medicine,New York Medical College,New York, N.Y. 10029.

12. Harrod, E. K., Cohen, M. M. Pediatrics, Springfield, 1969, 44, 128.13. Macek, M., Cytologia, Tokyo, 1967, 32, 165.14. Mold, J. W. Lancet, 1966, ii, 107.15. Szabo, A. J., Stewart, A. G., Joron, G. E. Can. med. Ass. J. 1967,

97, 286.

THE ELECTROCARDIOGRAM IN MALESWITH THE 47,XYY KARYOTYPE

SIR,-We have studied 9 males with the 47,XYY karyo-type against the background of Price’s findings I of prolongedP-R intervals, increased frequency of secondary R waves inlead Vl, and notching with reduction in the size of the swave in Vi in 20 males with 47,XYY karyotypes.Methods

7 of the 9 47,XYY patients were detected in surveys ofpatients in psychiatric institutions, and 2 were identifiedwhile in a medical ward. None had any symptoms or signsof heart-disease. 8 were between 19 and 29 years old, and 1was 49 years old. 8 had the 47,XYY karyotype, and 1 had amosaic 46,XY/47,XYY with 81 % of the cells with 47,XYY.6 of the patients have been described previously.2-4The following laboratory examinations were done on the

day of the first electrocardiographic examination: haemo-globin, sedimentation-rate, serum creatinine, protein, andelectrolytes including chlorides, sodium, potassium, bi-

carbonate, magnesium and calcium. The urine was

examined for glucose and albumin and the blood-pressurewas measured. The results of these examinations were allwithin the normal range.

All electrocardiograms were taken on the same electro-cardiograph, with a paper speed of 50 mm. per second,12 leads were taken, including leads I, II, III, and Vi_,,on three consecutive days in all but one patient, in whomwe only managed to get an electrocardiogram once. TheP-Q, QRS, Q-T, and R-R intervals, and the heights of theQ, R, R’, and s waves were measured. These measurementswere made in the limb leads as well as in the precordialleads in all electrocardiograms. The durations of the P-Q,QRS, and R-R intervals for all leads were calculated as

the mean duration for the electrocardiograms taken onthe three consecutive days, while the mean height of theQ, R, R’, and s waves were calculated for each lead on thethree consecutive days. All the results were compared withthe normal values reported for males aged 20-29 bySimonson. 5 The results of the electrocardiographicmeasurements are shown in the accompanying table.

Results

The mean P-Q interval was not increased (as seen in thetable), nor was there any significant difference between the

ELECTROCARDIOGRAPHIC READINGS IN THE 9 PATIENTS IN THIS STUDYCOMPARED WITH THOSE IN 26 PATIENTS REPORTED ELSEWHEREAND NORMAL CONTROLS

QRS, Q-T, and R-R intervals in our patients compared with asample of healthy males in the same age-group. None ofthe patients had secondary R waves in VI, The mean size ofthe s deflection in V, was l-28r)-0-66 mV, compared with anexpected value of 1.14 0.49 mV. The height of the Q andR for each lead was within the normal range.1. Price, W. H. Lancer, 1968, i, 1106.2. Nielsen, J. Br. J. Crim. 1968, 8, 186.3. Nielsen, J., Tsuboi, T., Tuver, B., Jensen, J. T., Sachs, J. Acta

psychiat. scand. 1969, 45, 402.4. Nielsen, J. ibid. suppl. 209.5. Simonson, E. Differentiation between Normal and Abnormal in

Electrocardiography. St. Louis, 1961.

1403

DiscussionThe frequency of incomplete right-bundle-branch block

in healthy males aged 18-40 has been found to be 9%,6 butonly 100 people were studied.We did not find incomplete right-bundle-branch block

in any of our 9 patients with the 47,XYY karyotype, but thiselectrocardiographic aberration has previously been foundin 5 of 26 patients with 47,XYY in two studies.I,7 Thenumber of patients with 47,XYY studied altogether is,however, small, and the methods of selecting patientsdiffer from study to study. The difference between 9% ofthe 100 healthy males with incomplete right-bundle-branchblock 6 and 5 of the total number of 35 patients with47,XYY with this aberration (14%) is, however, not

statistically significant, and more electrocardiographicstudies of males with 47,XYY are needed before anyconclusion can be drawn about the possibility of an in-creased frequency of incomplete right-bundle-branchblock in such patients.

Price found that the mean P-Q interval was significantlylonger in 20 patients with 47,XYY compared with a controlgroup, but the r-Q interval only exceeded the normal rangein one patient who also had a right-bundle-branch block.We have not found any significant difference in the meanP-Q interval in our patients with 47,XYY, compared with acontrol group 5 and this corresponds to the findings ofNoel et al. 7

The P-Q interval is susceptible to various factors includingthe position of the patient during the recording. All ourelectrocardiograms were taken under standard conditions,on patients who were lying down and had no symptoms orsigns of ill-health.No investigation has been made of a possible correlation

between bundle-branch block and prolonged P-Q interval inindividuals with normal chromosome constitutions, butthis seems very unlikely. The pooled results of the presentas well as the previous studies 1,7 of a total of 35 patientswith 47,XYY provide no evidence of a statistically signi-ficant increase in electrocardiographic aberrations.

EVA STEINESS.Cardiology Department,

University Hospital of Århus.

JOHANNES NIELSEN.Cytogenetic Laboratory,

Århus State Hospital, Denmark

ORANGE SOLES

SIR,-Dr. Bray (June 20, p. 1348) wonders whetherorange palms and soles are unusual in Nigerian children.The level of carotene is high in people resident in the palm-forest belt of Nigeria because of the consumption of redpalm oil, which is rich in this substance. The subcutaneousfat of these people becomes bright yellow after weaning.Yams may be prepared with palm oil, but this was not

often done during the war because of a shortage of palm oil.Cassava, prepared as garri (which I hate), contains palm oil:the tubers are peeled and grated, and the " flour" is

squeezed to remove the juice and then fried in palm oil.I have worked in the East Central State for nine years,

and this is a normal finding, unaffected by the recent war.I believe something has been published on it by workers atUniversity College Hospital, Ibadan, but, having lost all mybooks as a refugee. I cannot check this.

ANNE SEYMOUR.Worthing,Sussex.

SIR,-Dr. Bray’s account of two Nigerian children withdiscoloration of the palms and soles in association withraised serum-carotene levels reminds me of a like experience6. Said, S. I., Bryant, J. M. Circulation, 1956, 14, 993.7. Noel, B., Quack, B., Durand, Y., Rethoré, M.-O. Ann. Génét. 1969,

12, 223.

in 1951, when I was serving in Japan as pathologist to thecombined 29th British General Hospital/B.C.O.F. GeneralHospital at Kure.

I was asked to carry out investigations on an Australianofficer of about 50, whose complaint was of a yellow dis-coloration of his skin. While I did not see the soles of hisfeet, the pigmentation of the skin of his palms was strikinglydeeper than that of his forearms, face, or neck. His serum

proved to be abnormally yellow, owing to the presence ofcarotene in excessive amounts. Serum-bilirubin was

normal.

The source of the carotene in this instance was evidentlythe delicious mandarin oranges that are grown so success-fully in Japan. Such was our patient’s liking for them, hetold us, that when they were in season he ate little else.

G. A. K. MISSEN.

Department of Pathology,Guy’s Hospital,London S.E.1.

MYALGIA AND BIRD-KEEPING

SIR,-A previous letter documented the associationbetween bird-keeping and polymyalgia rheumatica or giant-cell arteritis.1 In pursuing the hypothesis that contact withbirds produces a greater frequency of muscle pain than theabsence of such contact, we have used a questionary whichincludes the following questions:

(a) Have you kept birds or been in close contact with birds inthe past five years ?

(b) Have you kept a cat or dog during the past five years ?(c) Have you had any severe and prolonged pains in the

muscles of the arms, legs, or upper back that required fre-quent visits to your doctor during the past six months ?

(d) Did you experience a sudden and severe deterioration inyour vision during the past six months ?

Two groups of persons answered this questionary. Firstwere 4041 people undergoing a periodic health examinationin our multiphasic test laboratory. It is our overall experi-ence that 80% of persons undertaking this check are foundto have no major health impairment by the examiningphysician. Second was a group of 75 respondents whoworked in stores that sell birds: the questionaries were sentto stores in the San Francisco Bay area and in Los Angeles.

In the first group of 4041 persons, myalgia was presentalmost twice as often in those who had kept birds as inthose who had not kept birds (see accompanying table).Among those who had bird contact, irrespective of whetherthey kept dogs or cats, 13-3% had complaints of musclepain; where dogs or cats as well as birds had all been keptthe percentage with muscle pain was 14-7%; these figurescontrast with 7-4% and 7-0% among the respective com-parison subgroups who had had no bird contact (P < -0005for each comparison, boxes c versus F, and A versus D inthe table). The figures show that, unlike bird-keeping,the keeping of dogs or cats has no association with musclepain. In those who had had bird contact, there was nosignificant difference in the percentage with muscle painbetween those who had or had not kept cats or dogs (boxesA versus B); the same is true when bird contact was absent(boxes D versus E), or when dog or cat contact was con-sidered irrespective of bird contact (boxes G versus H).

It is not merely the age of the bird-keepers that determines thepresence of myalgia. There were no differences in the mean agesor sex ratios of the 171 persons who had kept birds but no dogsor cats (box B in the table), when these were contrasted with 171persons randomly picked from those who had not kept birds,dogs, or cats (box E). The former group contained 39 males,average age 44-7 years, and 132 females, average age 50-5 years;the latter group contained 63 males, average age 45-6 years, and108 females, average age 50-3 years.We obtained Westergren erythrocyte-sedimentation rates and

1. Fessel, W. J. Lancet, 1969, ii, 1249.