- Email: [email protected]
CATCHING UP WITH THE CLOCK
839
findings reported by the different surgeons ranged from 18 to 85%. Minor abnormalities were recorded in from 3 to 45,%, and major changes, such as oedema, granulation, or ulceration, in from 0 to 50%. The surgeon who the least abnormals (17 out of 91) found no in any patient ; the one reporting the most abnormals (29 out of 34) found major changes The prevalence of clinical and radiographic in 50%. appearances believed to suggest bronchial lesions varied from 7 to’ 40% at the different hospitals. There were, therefore, wide differences in both clinical and bronchoscopic diagnoses ; but there was no clear relationship between the two. Thus, at one hospital 7% were judged to have clinical evidence of bronchial disease and 50% bronchoscopic evidence, compared with 40% and 33% at another hospital. The groups may not have been comparable-it is impossible to judge from the data in the report-but it seems unlikely that the wide differences in bronchoscopic reports were entirely due to differences in the types of patients examined. Some time ago we suggested that an apparently normal mucosa. at bronchoscopy may not exclude gross bronchial disease.2In the British Tuberculosis Association investigation 95 patients had a pneumonectomy or lobectomy, and the bronchus at the point of section was examined microscopically. Of the 95, 56 had been reported to have no bronchoscopic abnormality ;; in only 2 of these 56 was there no microscopic evidence of tuberculosis, while in 32 (57%) there were epithelioid tubercles or a severe inflammatory reaction with tuberculous granulation tissue, ulceration of the mucosa, and fibrosis. Abnormal bronchoscopic appearances had been reported in 39 ;no microscopic evidence of bronchial tuberculosis was found in 2 and only minor changes in 10 (25%). It seems that the bronchoscopic report can sometimes give the physician a very inaccurate indication of the state of the bronchi ;for there may be great differences not only between the interpretation by different observers of what they see, but also between their reports and the microscopic appearances.
reported
gross changes
POSTOPERATIVE METABOLIC CHANGES
AN operation, like any other injury, produces a characteristic metabolic disturbance. Twenty years ago Cuthbertson3 described the brisk katabolic phase which after a few days changes rather abruptly to a less intense but longer period of anabolism. Moore,4 who has studied the matter intensively, has summarised present knowledge. He believes the early katabolism to be due to adrenal hormones and points out that its cessation is marked by features (diuresis and transient eosinophilia) that are also observed on withdrawal of administered cortisone. It is at this stage, too, that wound healing begins in earnest. Moore finds that it takes about a month to rebuild the protein squandered in the katabolic spree, and another month to restore lost fat. This pattern is of course often disturbed by specific effects of particular diseases or operations. Is all this metabolic to-do necessary ? Apparently not, for if a second operation has to be performed within a few days of the first, the katabolic response is absent and yet recovery may be unimpaired. Moore believes that this response is homoeostatic, and that the protein breakdown mobilises amino-acids for wound repair. This seems odd, if repair does not get under way until the katabolic phase is over. A clean operation under aneesthesia is such an artificial circumstance that the body’s response may not be optimal. The same response, or something very like it, occurs as part of the general illness of inflammation, and its teleological significance should perhaps be sought there. 2. Lancet, 1951, i, 280. 3. Cuthbertson, D. P. Quart. J. Med. 1932, 1, 233. 4. Moore, F. D. Ann. Surg. 1953, 137, 289.
CATCHING
UP WITH
THE
CLOCK
TiiERE are many physiological diurnal variations ; the most familiar is the cycle of sleep and wakefulness, and associated with it are the rhythms of body-temperature, metabolic rate, and heart-rate, the fluctuations in the composition of the blood and in renal function, and many other changes.1-3 Kleitman, who has been one of the most prominent investigators of these changes, has proposed that diurnal rhythms should be distinguished from periodicity by their persistence when, for example, the cycle of sleep and wakefulness is changed. A worker who is transferred from a day to a night shift has to face not only alterations in the social pattern of his life but physiological stresses caused by the persistence of the diurnal rhythms. The daily variation in body-temperature is the simplest of these rhythms to study, and there are many data2 which show that the commonest pattern consists in a gradual rise of temperature during the day, reaching a peak about 6 P.M., followed by a fall, which may be more abrupt, the lowest level usually being reached between 2 A.M. and 4 A.M. The difference between the highest and lowest bodytemperature is usually 1.5°-2.0°F, but there is considerable individual variation from day to day in the same person, and from subject to subject, as well as in the pattern of the fluctuation. When work is changed from day to night, the usual diurnal rhythm changes only gradually, so at first the night worker will have a peak of body-temperature during sleep and a low temperature during work. A new rhythm is eventually established so that body-temperature rises during the night and falls in the day, but this change may occupy a week or more. Once again there is considerable individual variation in the time taken ; some people have rhythms which adapt rapidly and others slowly. This individual variation may partly account for the ease or difficulty with which different people can change their hours of work. Strughold4 has lately examined another situation in which the day-night cycle is altered. In long-distance flights the aircraft’s passengers must change their watches with bewildering frequency ; and the " physiological cycle," adjusted to day and night in, say, London, may be very much out of step when the journey ends in Tokyo thirty-six hours later. Strughold has followed (though not in great detail) the diurnal temperature rhythm before, during, and after flights between London and New York, when there is- a time shift of five hours. The body-temperature rhythm is out of phase at first, but within a few days the peak is once more reached in the afternoon, with the lowest readings at night. The time taken for this physiological adjustment is probably very variable, but more observations are needed on this
point. Has the fact that the diurnal rhythms are out of step with the day-night cycles any important effect, or is it only of academic interest ? The pattern of sleep is disturbed ; and the many other rhythms, which have not yet been fully investigated, are also upset. Kleitman has shown, too, that the curve of efficiency in a number of different tasks follows the body-temperature curve. Accuracy and speed of performance increased as the bodytemperature rose, and declined when body-temperature There seems, then, to be a good explanation fell. for the traveller’s common complaint of fatigue and lack of efficiency in the days following a long-distance flight. Strughold points out that this is certainly not a serious medical problem, but it has its important aspects. Diplomats who fly long distances to attend international conferences may not be as capable as they would normally be, or they may reach their -peak of efficiency at the 1. Kleitman, N. Physiol. Rev. 1949, 29, 1. 2. Kleitman, N. Sleep and Wakefulness. Chicago, 1939. 3. Mills, J. N. J. Physiol. 1951, 113, 528. 4. Strughold, H. J. aviat. Med. 1952, 23, 464.
840 wrong times, being perhaps at their nadir during critical discussions. Playing at home may be as important an advantage in this field as on others. -
THE SOCIAL ANIMAL neurotic is isolated from the community, to which THE Dr. Maxwell Jones has tried the he cannot’ adjust. effect of giving him a hair of the dog that bit him, by guiding and absorbing him into another social com-
munity-that of the hospital. Doctors, nurses, and patients provide between them a social unit with a therapeutic power comparable to that of a united family, or of the esprit-de-corps of other groups. -
In
a
new
bookDr. Maxwell Jones describes three these lines. First he treated soldiers " effort syndrome," in an emergency
experiments on suffering from hospital during
Here he. mainly developed the war. the educational approach, teaching patients the mental mechanisms of their symptoms ; and he found that explanations were readily accepted when they had -the weight of group acceptance behind them.- The second experiment was with psychodrama," which gave patients the chance to’ act out their difficulties or to see These two methods he them re-enacted by others. afterwards modified for the rehabilitation of repatriated prisoners-of-war who were having difficulty in readjusting to civilian life. His most important and most lasting experiment, however, described in detail, was the establishment of the industrial neuresis unit at Belmont Hospital, Sutton. Here he has treated patients of a very different type (though the difference is perhaps not made clear enough to the reader)-—to wit, unemployed neurotics of long standing, often considered unemployable by the authorities, patients with " severe character disorders in poor personalities," " some of the most antisocial elements in society." The task was to absorb these social casualties into the transitional community of the unit, to instil sorne " comrimnal responsibilit " into people who had no real place in society before, and to prepare-them for their outside role after discharge. This obviously demands more than average enthusiasm, optimism, energy, and devotion to the idea from all who collaborate in the work, and especially from the nursing staff. Probably the most instructive and revolutionary parts of the book are those explaining the nurse’s position, the difficulties arising out of the unconventional part she is asked to play in the community of the unit, and the solutions attempted and achieved. Dr. Maxwell Jonesis colleagues-Dr. A. A. Baker, Dr. Thomas Freeman, Dr. Julius Merry, Dr. B. A. Pomryn, Mr. Joseph Sandler, PH.D., and Miss Joy Tuxford-report in separate chapters on their special problems : psychotherapy of neurotic inpatients is criticised and justified, techniques of group formations are disentangled, and the special hazards of vocational guidance are described. Follow-up study of these patients seems impossible ; nevertheless it was tried, and we even find the team in search of a control group of untreated cases. They were not able to collect them, but the search disclosed a still more solitary and demoralised layer of unemployable psychiatric patients, who refused treatment even in a unit like that at Belmont. Six months after discharge about 100 patients were visited, of whom almost half were working, some of them under sheltered conditions. This seems a satisfactory practical result, justifying Dr. Maxwell Jones’s work. It is encouraging to see from his report how his idealism and pioneer spirit have won the support not only of able colleagues, but also of Ministries and other official bodies inside and outside the National Health Service. ’
,
1. Social Psychiatry : A Study of Therapeutic Communities. London: Tavistock Publications in collaboration with Routledge 1952. Pp. 186. 18s. & Kegan Paul.
KERNICTERUS
KERNICTERUS, nuclear
masses
a
of
peculiar yellow staining the
brain
in
of the
neonates, has long
interested clinicians, pathologists, and hsematologists. Originally this condition, which gives rise to a varied clinical picture, 1was believed to be toxic, possibly hepatogenous ; later the cause was thought to be came to be regarded as only a contri. sepsis,3 but this 4 factors When butory blood-group incompatibility was correlated with icterus gravis, many thought that the problem of kernicterus was solved ; indeed, Claireaux5 suggested that kernicterus was always due to jaundice resulting from haemolytic disease of the newborn. Aidin
et a1.6, however, described 25 cases of kernicterus in premature infants without any evidence of hsemolytic disease ; and their findings have been confirmed in a further 10 cases by Dr. Govan and Dr. Scott.7 These workers also examined the brains of 3 premature infants who had lived only 48-72 hours and where there had been a difficult birth ; and in these they found histological evidence of brain damage indistinguishable from that in kernicterus due to haemolytic disease of the newborn. They concluded that anoxia was the primary cause, and deposition of pigment a secondary factor. This explanation, however, does not accord with all the facts. Anoxia does not necessarily accompany the birth of a full-term erythroblastotic infant; usually the infant seems perfectly healthy until it becomes jaunl.iced. Furthermore, the serum-l7ilirubin of the neonate destined to have kernicterus is usually, though not always, much raised.. Signs of kernicterus come on pari passu with the jaundice, but the disorder does not seem yet to have been diagnosed at the time of birth. It is doubtful if the theory of antigen-antibody reaction in the brain as a cause of kernicterus is any longer tenable ; in the worst form of hsemolytic disease
of the newborn-namely, hydrops foetalis—histological evidence of brain damage has not hitherto been described. Experimentally bilirubin can cause a brain lesion similar to that of kernicterus,8but only if its level is very much higher than that found in erythroblastosis. A familial non-haemolytic jaundice apparently accounted for kernicterus in five members of a family described by Crigler and Najjar 9 ; and in a letter that appears on a later page of this issue Dr. Forrester and Mr. Bevis suggest that the cause may be pigment derived from abnormal haemoglobin metabolism. Gerrardconcluded that hypoglycaemia was not the cause, and he suggested that neither anoxia nor liver damage, but some primary biochemical dysfunction, such as hexokinase inhibition, might prove the underlying factor. Dr. Saunders 10 has suggested that the cause may be the withdrawal of an inhibiting substance derived from the placenta. Clearly our knowledge of kernicterus is very far from complete. It seems, however, that the kernicterus in erythroblastosis and in jaundiced-and non-jaundiced -premature infants should be considered together, although the manifestations differ somewhat." It seems, too, that replacement transfusion will reduce the risk of kernicterus in infants with haemolytic disease of the newborn ; and early induction of labour where there is any likelihood of haemolytic disease in the infant should be avoided. 1. Evans, P. R., Polani, P. E. Quart. J. med. 1950, 19, 129. 2. Gerrard, J. Brain, 1952, 75, 526. 3. Biemond, A., van Creveld, S. Arch. Dis. Childh. 1937, 173. 4. de Bruyne, J. I., van Creveld, S. Ibid, 1948, 23, 84. 5. Claireaux, A. Ibid, 1950, 25, 61. 6. Aidin, R., Corner, B., Tovey, G. Lancet, 1950, i, 1153. 7. Govan, A. D. T., Scott, J. M. Ibid, March 28, 1953, p. 611. 8. Küster, F., Krings, H. Ibid, 1950, i, 974. 9. Crigler, J. F., Najjar, J. A. Pediatrics, 1952, 10, 169. 10. Saunders, C. M. Lancet, April 18, 1953, p. 799. 11. Aidin, R., Tovey, G. H. J. clin. Path. 1950, 3, 376.
12,
findings reported by the different surgeons ranged from 18 to 85%. Minor abnormalities were recorded in from 3 to 45,%, and major changes, such as oedema, granulation, or ulceration, in from 0 to 50%. The surgeon who the least abnormals (17 out of 91) found no in any patient ; the one reporting the most abnormals (29 out of 34) found major changes The prevalence of clinical and radiographic in 50%. appearances believed to suggest bronchial lesions varied from 7 to’ 40% at the different hospitals. There were, therefore, wide differences in both clinical and bronchoscopic diagnoses ; but there was no clear relationship between the two. Thus, at one hospital 7% were judged to have clinical evidence of bronchial disease and 50% bronchoscopic evidence, compared with 40% and 33% at another hospital. The groups may not have been comparable-it is impossible to judge from the data in the report-but it seems unlikely that the wide differences in bronchoscopic reports were entirely due to differences in the types of patients examined. Some time ago we suggested that an apparently normal mucosa. at bronchoscopy may not exclude gross bronchial disease.2In the British Tuberculosis Association investigation 95 patients had a pneumonectomy or lobectomy, and the bronchus at the point of section was examined microscopically. Of the 95, 56 had been reported to have no bronchoscopic abnormality ;; in only 2 of these 56 was there no microscopic evidence of tuberculosis, while in 32 (57%) there were epithelioid tubercles or a severe inflammatory reaction with tuberculous granulation tissue, ulceration of the mucosa, and fibrosis. Abnormal bronchoscopic appearances had been reported in 39 ;no microscopic evidence of bronchial tuberculosis was found in 2 and only minor changes in 10 (25%). It seems that the bronchoscopic report can sometimes give the physician a very inaccurate indication of the state of the bronchi ;for there may be great differences not only between the interpretation by different observers of what they see, but also between their reports and the microscopic appearances.
reported
gross changes
POSTOPERATIVE METABOLIC CHANGES
AN operation, like any other injury, produces a characteristic metabolic disturbance. Twenty years ago Cuthbertson3 described the brisk katabolic phase which after a few days changes rather abruptly to a less intense but longer period of anabolism. Moore,4 who has studied the matter intensively, has summarised present knowledge. He believes the early katabolism to be due to adrenal hormones and points out that its cessation is marked by features (diuresis and transient eosinophilia) that are also observed on withdrawal of administered cortisone. It is at this stage, too, that wound healing begins in earnest. Moore finds that it takes about a month to rebuild the protein squandered in the katabolic spree, and another month to restore lost fat. This pattern is of course often disturbed by specific effects of particular diseases or operations. Is all this metabolic to-do necessary ? Apparently not, for if a second operation has to be performed within a few days of the first, the katabolic response is absent and yet recovery may be unimpaired. Moore believes that this response is homoeostatic, and that the protein breakdown mobilises amino-acids for wound repair. This seems odd, if repair does not get under way until the katabolic phase is over. A clean operation under aneesthesia is such an artificial circumstance that the body’s response may not be optimal. The same response, or something very like it, occurs as part of the general illness of inflammation, and its teleological significance should perhaps be sought there. 2. Lancet, 1951, i, 280. 3. Cuthbertson, D. P. Quart. J. Med. 1932, 1, 233. 4. Moore, F. D. Ann. Surg. 1953, 137, 289.
CATCHING
UP WITH
THE
CLOCK
TiiERE are many physiological diurnal variations ; the most familiar is the cycle of sleep and wakefulness, and associated with it are the rhythms of body-temperature, metabolic rate, and heart-rate, the fluctuations in the composition of the blood and in renal function, and many other changes.1-3 Kleitman, who has been one of the most prominent investigators of these changes, has proposed that diurnal rhythms should be distinguished from periodicity by their persistence when, for example, the cycle of sleep and wakefulness is changed. A worker who is transferred from a day to a night shift has to face not only alterations in the social pattern of his life but physiological stresses caused by the persistence of the diurnal rhythms. The daily variation in body-temperature is the simplest of these rhythms to study, and there are many data2 which show that the commonest pattern consists in a gradual rise of temperature during the day, reaching a peak about 6 P.M., followed by a fall, which may be more abrupt, the lowest level usually being reached between 2 A.M. and 4 A.M. The difference between the highest and lowest bodytemperature is usually 1.5°-2.0°F, but there is considerable individual variation from day to day in the same person, and from subject to subject, as well as in the pattern of the fluctuation. When work is changed from day to night, the usual diurnal rhythm changes only gradually, so at first the night worker will have a peak of body-temperature during sleep and a low temperature during work. A new rhythm is eventually established so that body-temperature rises during the night and falls in the day, but this change may occupy a week or more. Once again there is considerable individual variation in the time taken ; some people have rhythms which adapt rapidly and others slowly. This individual variation may partly account for the ease or difficulty with which different people can change their hours of work. Strughold4 has lately examined another situation in which the day-night cycle is altered. In long-distance flights the aircraft’s passengers must change their watches with bewildering frequency ; and the " physiological cycle," adjusted to day and night in, say, London, may be very much out of step when the journey ends in Tokyo thirty-six hours later. Strughold has followed (though not in great detail) the diurnal temperature rhythm before, during, and after flights between London and New York, when there is- a time shift of five hours. The body-temperature rhythm is out of phase at first, but within a few days the peak is once more reached in the afternoon, with the lowest readings at night. The time taken for this physiological adjustment is probably very variable, but more observations are needed on this
point. Has the fact that the diurnal rhythms are out of step with the day-night cycles any important effect, or is it only of academic interest ? The pattern of sleep is disturbed ; and the many other rhythms, which have not yet been fully investigated, are also upset. Kleitman has shown, too, that the curve of efficiency in a number of different tasks follows the body-temperature curve. Accuracy and speed of performance increased as the bodytemperature rose, and declined when body-temperature There seems, then, to be a good explanation fell. for the traveller’s common complaint of fatigue and lack of efficiency in the days following a long-distance flight. Strughold points out that this is certainly not a serious medical problem, but it has its important aspects. Diplomats who fly long distances to attend international conferences may not be as capable as they would normally be, or they may reach their -peak of efficiency at the 1. Kleitman, N. Physiol. Rev. 1949, 29, 1. 2. Kleitman, N. Sleep and Wakefulness. Chicago, 1939. 3. Mills, J. N. J. Physiol. 1951, 113, 528. 4. Strughold, H. J. aviat. Med. 1952, 23, 464.
840 wrong times, being perhaps at their nadir during critical discussions. Playing at home may be as important an advantage in this field as on others. -
THE SOCIAL ANIMAL neurotic is isolated from the community, to which THE Dr. Maxwell Jones has tried the he cannot’ adjust. effect of giving him a hair of the dog that bit him, by guiding and absorbing him into another social com-
munity-that of the hospital. Doctors, nurses, and patients provide between them a social unit with a therapeutic power comparable to that of a united family, or of the esprit-de-corps of other groups. -
In
a
new
bookDr. Maxwell Jones describes three these lines. First he treated soldiers " effort syndrome," in an emergency
experiments on suffering from hospital during
Here he. mainly developed the war. the educational approach, teaching patients the mental mechanisms of their symptoms ; and he found that explanations were readily accepted when they had -the weight of group acceptance behind them.- The second experiment was with psychodrama," which gave patients the chance to’ act out their difficulties or to see These two methods he them re-enacted by others. afterwards modified for the rehabilitation of repatriated prisoners-of-war who were having difficulty in readjusting to civilian life. His most important and most lasting experiment, however, described in detail, was the establishment of the industrial neuresis unit at Belmont Hospital, Sutton. Here he has treated patients of a very different type (though the difference is perhaps not made clear enough to the reader)-—to wit, unemployed neurotics of long standing, often considered unemployable by the authorities, patients with " severe character disorders in poor personalities," " some of the most antisocial elements in society." The task was to absorb these social casualties into the transitional community of the unit, to instil sorne " comrimnal responsibilit " into people who had no real place in society before, and to prepare-them for their outside role after discharge. This obviously demands more than average enthusiasm, optimism, energy, and devotion to the idea from all who collaborate in the work, and especially from the nursing staff. Probably the most instructive and revolutionary parts of the book are those explaining the nurse’s position, the difficulties arising out of the unconventional part she is asked to play in the community of the unit, and the solutions attempted and achieved. Dr. Maxwell Jonesis colleagues-Dr. A. A. Baker, Dr. Thomas Freeman, Dr. Julius Merry, Dr. B. A. Pomryn, Mr. Joseph Sandler, PH.D., and Miss Joy Tuxford-report in separate chapters on their special problems : psychotherapy of neurotic inpatients is criticised and justified, techniques of group formations are disentangled, and the special hazards of vocational guidance are described. Follow-up study of these patients seems impossible ; nevertheless it was tried, and we even find the team in search of a control group of untreated cases. They were not able to collect them, but the search disclosed a still more solitary and demoralised layer of unemployable psychiatric patients, who refused treatment even in a unit like that at Belmont. Six months after discharge about 100 patients were visited, of whom almost half were working, some of them under sheltered conditions. This seems a satisfactory practical result, justifying Dr. Maxwell Jones’s work. It is encouraging to see from his report how his idealism and pioneer spirit have won the support not only of able colleagues, but also of Ministries and other official bodies inside and outside the National Health Service. ’
,
1. Social Psychiatry : A Study of Therapeutic Communities. London: Tavistock Publications in collaboration with Routledge 1952. Pp. 186. 18s. & Kegan Paul.
KERNICTERUS
KERNICTERUS, nuclear
masses
a
of
peculiar yellow staining the
brain
in
of the
neonates, has long
interested clinicians, pathologists, and hsematologists. Originally this condition, which gives rise to a varied clinical picture, 1was believed to be toxic, possibly hepatogenous ; later the cause was thought to be came to be regarded as only a contri. sepsis,3 but this 4 factors When butory blood-group incompatibility was correlated with icterus gravis, many thought that the problem of kernicterus was solved ; indeed, Claireaux5 suggested that kernicterus was always due to jaundice resulting from haemolytic disease of the newborn. Aidin
et a1.6, however, described 25 cases of kernicterus in premature infants without any evidence of hsemolytic disease ; and their findings have been confirmed in a further 10 cases by Dr. Govan and Dr. Scott.7 These workers also examined the brains of 3 premature infants who had lived only 48-72 hours and where there had been a difficult birth ; and in these they found histological evidence of brain damage indistinguishable from that in kernicterus due to haemolytic disease of the newborn. They concluded that anoxia was the primary cause, and deposition of pigment a secondary factor. This explanation, however, does not accord with all the facts. Anoxia does not necessarily accompany the birth of a full-term erythroblastotic infant; usually the infant seems perfectly healthy until it becomes jaunl.iced. Furthermore, the serum-l7ilirubin of the neonate destined to have kernicterus is usually, though not always, much raised.. Signs of kernicterus come on pari passu with the jaundice, but the disorder does not seem yet to have been diagnosed at the time of birth. It is doubtful if the theory of antigen-antibody reaction in the brain as a cause of kernicterus is any longer tenable ; in the worst form of hsemolytic disease
of the newborn-namely, hydrops foetalis—histological evidence of brain damage has not hitherto been described. Experimentally bilirubin can cause a brain lesion similar to that of kernicterus,8but only if its level is very much higher than that found in erythroblastosis. A familial non-haemolytic jaundice apparently accounted for kernicterus in five members of a family described by Crigler and Najjar 9 ; and in a letter that appears on a later page of this issue Dr. Forrester and Mr. Bevis suggest that the cause may be pigment derived from abnormal haemoglobin metabolism. Gerrardconcluded that hypoglycaemia was not the cause, and he suggested that neither anoxia nor liver damage, but some primary biochemical dysfunction, such as hexokinase inhibition, might prove the underlying factor. Dr. Saunders 10 has suggested that the cause may be the withdrawal of an inhibiting substance derived from the placenta. Clearly our knowledge of kernicterus is very far from complete. It seems, however, that the kernicterus in erythroblastosis and in jaundiced-and non-jaundiced -premature infants should be considered together, although the manifestations differ somewhat." It seems, too, that replacement transfusion will reduce the risk of kernicterus in infants with haemolytic disease of the newborn ; and early induction of labour where there is any likelihood of haemolytic disease in the infant should be avoided. 1. Evans, P. R., Polani, P. E. Quart. J. med. 1950, 19, 129. 2. Gerrard, J. Brain, 1952, 75, 526. 3. Biemond, A., van Creveld, S. Arch. Dis. Childh. 1937, 173. 4. de Bruyne, J. I., van Creveld, S. Ibid, 1948, 23, 84. 5. Claireaux, A. Ibid, 1950, 25, 61. 6. Aidin, R., Corner, B., Tovey, G. Lancet, 1950, i, 1153. 7. Govan, A. D. T., Scott, J. M. Ibid, March 28, 1953, p. 611. 8. Küster, F., Krings, H. Ibid, 1950, i, 974. 9. Crigler, J. F., Najjar, J. A. Pediatrics, 1952, 10, 169. 10. Saunders, C. M. Lancet, April 18, 1953, p. 799. 11. Aidin, R., Tovey, G. H. J. clin. Path. 1950, 3, 376.
12,