ceed the elite and British groups. In short, these apparently plump arms contained not only fat but fluid not otherwise obvious on clinical exami¬ nation. The implications of this find¬ ing in terms of bodily growth, intel¬ lectual alertness, and, above all, resistance to infection are only too obvious and are manifested in the high incidence, morbidity, and mor¬ tality from infections and the rapid¬ ity with which these children can be triggered off into clinical malnutri¬ tion syndromes.There is, then, a growing realisa¬ tion of the complex interaction be¬ tween the many factors leading to PCM. Low intake of important food factors-yes; but of itself not a suffi¬ cient explanation. Others include low general standards of living, and taboos, on feeding eggs to young chil¬ dren for instance, alleged to have de¬ veloped to ensure that the father-the worker-gets what he needs in order to do his farming. In this connection one study of rural family food con¬ sumption showed a rise in the inci¬ dence of malnutrition in the children that coincided with a sudden increase in the family total calorie intake oc¬ curring with the return to intense farming activity in anticipation of the coming rains. And then, constant infections, with the accompanying loss of appetite, poor digestion, and diminished absorption of food, are now accepted as vital factors contrib¬ uting to undernourishment and pre¬ cipitating malnutrition. Gastroenter¬ itis is undoubtedly the biggest contributor to marasmus and to in¬ fant mortality, and measles, the great villain occurs in epidemics of great severity and high mortality, and can be seen to be followed by sudden on¬ set of kwashiokor a few weeks later.Severe diarrhoea often accompanies the acute phase, and it is easy to un¬ derstand that the rash, so evident as Koplik spots in the mouth, extends down into the gut and gives rise to mucosal damage and malabsorptionand so it is. Disaccharide intolerance has been shown to be present and sometimes persists and is associated with other malabsorptions. Further¬ more, some interesting recent work at Ahmadu Bello University Hospital in Zaria, Nigeria, has pinpointed an actual positive protein-losing enteropathy of up to 4 to 5 gm daily, suffi¬ cient to give rise to oedema even in well-fed subjects with nephrotic syn¬ drome.So, in summary the concept now ac¬ cepted is that malnutrition does notwill not-occur solely from inadequate protein or calorie intake in a healthy child, even in rural Africa, but results from the constant ill health, infec¬ tions, malabsorption, and so on that are the normal lot of mankind during the first few years of life, until some degree of immunity to a host of infec¬ tions has been achieved. But adequate immunity fails to develop in the un¬ dernourished, and infections flourish; and so the wheel goes round and round and the end result is the sur¬ vival of the toughest and luckiest 55% to 65% of those born into the African world-natural selection.It follows, of course, that the plump, well-nourished children of the African el...

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A case report of tracheal atresia with congenital absence of the radii is described. The authors suggest that this represents an addition to the VATER association.~J EXI~'~'~,~Gh; of tracheal atresia with congenital absence of the radii has not previously been reported. Kluthl described 96 anatomical variations affecting the trachea, bronchi, and esophagus. One of the variations is described as a normal larynx, followed by an atretic strand with a normal. distal trachea dividing into two main bronchi. Between the esophagus and the normal segment of the trachea there is a fistula (Fig. 1). We could find only two patients of this variation reported in the literature, neither of whom had associated congenital absence of the radii. Case ReportA 2,720-gram male infant was vaginally delivered at term to a 25-year-old primigravida. The pregnancy was uncomplicated, and no medications were taken. Smoking and alcohol consumption was denied. At delivery the infant did not cry and was limp and cyanotic. The forearms were short, with radial deviation of the hands. Intubation was attempted, with clear visualization of the laryngeal cords; but a 3.0-mm endotracheal tube could not be advanced beyond the cords. The child expired 30 minutes after birth. Autopsy showed trachea atresia with tracheosophageal fistula, as shown in Figure 1. The larynx was normal. Congenital absence of the radii with normal thumbs was the only other anomaly found.Chromosomal analysis indicated a 46-XY karyotype.'~c. 1. Tracheal atresia with trac~e~escap~ageal fistula.

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