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HÆMOLYTIC DISEASE OF THE NEWBORN
765 third showed areas of focal infiltration and necrosis near the lateral ventricles, perivascular cuffs, and infiltration in the ependyma ; but similar changes were found in its mother and a twin examined as controls, as well as in two other controls. No abnormalities were seen in the brains of three cats inoculated with filtrate of normal brain of a cat or in twelve normal controls. The results of bacteriological investigations were inconclusive.
It
was
suggested
that cats
are
liable to be infected
with neurotropic viruses and may therefore act as a reservoir from which the infection could be transmitted to human beings. The number of animal species known to be affected by various virus diseases is increasing, and much has recently been learnt on the links between man and animal infection. The cat appears to have been strangely overlooked in these studies. Dr. G. H. Jennings in his paper of April 12 states that many homes from which his patients were coming had cats. It may well be worth examining some of these cats, and generally paying more attention to this animal. WILLIAM N. ROGERS. Epsom.
CINEPLASTIC OPERATIONS
SIR,-In recent issues I have read with considerable interest several articles and letters concerning the value of cineplastic operations for amputation of the upper extremity. As an exponent of this method in the United States for the past twenty years, I have always taken the view that there is no one device or procedure that can answer the needs of every arm amputee. My practice has been to employ cineplasty along with other devices such as the utility hook, the mechanical hand, or other special mechanical prosthetic appliances as a reservoir from
which we can select the one which will best fit the needs of each specific case. In my opinion the device or method must be fitted not to the person’s stump but to his whole personality, bearing in mind the psychological and vocational as well as the economic aspects. Regarded in this way, we will find that cineplasty has its place as a special measure to meet the needs of special persons rather than as a solution to the problems of all amuutees. HENRY H. KESSLER. Newark, New Jersey.
HÆMOLYTIC DISEASE OF THE NEWBORN SiB,—May I comment on your interesting annotation (April 5), and on Sir Leonard Parsons’s letter (April 19) ? Nomenclature in haematology is notoriously vague ; indeed it does not appear to be clear what each hsematologist means by an erythroblast. May I suggest that instead of " haemolytic disease of the newborn " there be a new classification under the heading " Rhesus diseases of the newborn," to include (i) erythroblastosis or congenital anaemia ; (ii) icterus gravis neonatorum ; and (iii) hydrops foetalis. Such a classification does, I think, agree with present-day knowledge. In (i) the antibody has attacked mainly the haemopoietic system of the child, and the disease is a haemolytic congenital anaemia. In (ii) the liver cells and, either primarily or secondarily, the brain and extrapyramidal cells are attacked by the antibody or antibodies ; this is essentially a toxic condition, unconnected with haemolysis. In (iii), the gravest of the diseases, the antibody has attacked all the internal organs, with the well-known result of stillbirth or an oedematous, peeling, fcetus destined to live only a few hours. In these three conditions it may seem that the maternal antibody, whether single, compound, or incomplete (blocking), may be selective for certain tissues. Regarding treatment, surely Sir Leonard Parsons would not suggest that the logical treatment of a severe case of icterus gravis, where, as often as not, there is no ansemia, is to transfuse with Rh-negative blood " to correct the anaemia." Exsanguination transfusion is no new treatment; many years ago it was practised by Sir John Fraser, in Edinburgh, for the treatment and prevention of shock due to burns. Finally, in respect of mortality, Sir Leonard gives a figure of 27 % for these babies at his clinic since he started to transfuse Rh-negative blood. In my own small series, .since 1942, the mortality is nil, but in view of the
unfortunate incidence of kernicterus I would have welcomed a mortality of more than 27 %. To my mind it is the end-result that matters, not the immediate mortality ; and further careful consideration of children two years after survival of the disease is needed. HENRY THIRD. Nelson, Lanes. CHILD GUIDANCE IN OLD AGE SiR,-The meshes of the net spread by Professor Mackintosh in your issue of May 17 are a little too plainly visible. Chaff will not trap the wary old bird. I appreciate the spirit of mischief that has crept into the latest of his pastoral letters ; but will he tell us, who have changed our occupation at 65, how to recognise that even for the new task our powers have become inadequate and a proper opportunity for ridicule by our loved young ones ? Perhaps, after all, I am enmeshed in his snare ! PHOENIX. ADVICE ON THUNDERSTORMS SIR,-Your note on thunderstorms (May 17, p. 682) interested me. I would like to describe the precautions taken by a family I once knew. To permit fireballs to pass safely through the house without striking off their legs they used to open doors and windows and sit with their feet on the table. These precautions were invariably effective. In addition the mother encouraged her children by the assurance that every flash or bang meant that the storm was a hundred miles farther off. I believe they heard storms raging in New York or Siberia. This assurance was also effective and none ’
broke down under the strain.
G. C. PETHER.
Colchester.
TECHNIQUE OF PROSTATECTOMY
SiR,-The correspondence following the article by Terence Millin1 introducing retropubic- prostaticadenomectomy showed the interest in methods of curing prostatic obstruction. The bulk of prostatectomies are, no doubt, carried out by general surgeons, and the nonurologist has at times to steer his barque into a somewhat ammoniacal breeze and navigate the narrows of the bladder neck. Some of those who do not specialise in urology have not the opportunity or inclination to acquire the special skill called for outside the oldfashioned suprapubic enucleation, the disadvantages of which are the wet condition of the patient, the frequent changes of dressings after operation, the unsightly
Mr.
scar, and sometimes
subsequent ventral hernia. These largely avoided by adopting the well-known surgical principle of draining through an incision separate from the main operative one-a method I have been using for about three years. In the one-stage operation a median incision is made disadvantages
can
a
be
from the pubes to near the umbilicus, the prostate is enucleated through a vertical incision low in the bladder, and the bleeding is controlled by irrigation or packing. With the help of two fingers in the bladder, the peritoneum is stripped as high as possible so that the anterior part of the dome of the bladder as it recedes backwards is laid bare ; a de Pezzer catheter is inserted through a stab-wound in this region, and the hole made watertight by a circular catgut suture ; the catheter is then brought out by a track made through either rectus muscle and sheath and a skin stab, so that it passes obliquely upwards to one or other side, coming out just below the umbilicus. In the two-stage operation, the first stage consists of an incision starting about one inch above the umbilicus over the right rectus muscle and passing downwards and medially Where to about two inches below it and towards the midline. the bladder is not large, the downward extension may have to be greater. The anterosuperior surface of the bladder is laid bare and the de Pezzer catheter inserted as above. This leaves the area immediately abovethe pubes free of adhesions, At the second a virgin field for the actual prostatectomy. stage an incision of the Pfannenstiehl type is preferred ; this is a transverse incision about one inch above the pubes through the skin and rectus aponeuroses, with separation of the rectus muscles. The prostate is removed through a low bladder-incision. Alternately, a vertical incision, inclining to the left as it passes upwards, may be used. 1.
Lancet, 1945, ii, 693.
It
was
suggested
that cats
are
liable to be infected
with neurotropic viruses and may therefore act as a reservoir from which the infection could be transmitted to human beings. The number of animal species known to be affected by various virus diseases is increasing, and much has recently been learnt on the links between man and animal infection. The cat appears to have been strangely overlooked in these studies. Dr. G. H. Jennings in his paper of April 12 states that many homes from which his patients were coming had cats. It may well be worth examining some of these cats, and generally paying more attention to this animal. WILLIAM N. ROGERS. Epsom.
CINEPLASTIC OPERATIONS
SIR,-In recent issues I have read with considerable interest several articles and letters concerning the value of cineplastic operations for amputation of the upper extremity. As an exponent of this method in the United States for the past twenty years, I have always taken the view that there is no one device or procedure that can answer the needs of every arm amputee. My practice has been to employ cineplasty along with other devices such as the utility hook, the mechanical hand, or other special mechanical prosthetic appliances as a reservoir from
which we can select the one which will best fit the needs of each specific case. In my opinion the device or method must be fitted not to the person’s stump but to his whole personality, bearing in mind the psychological and vocational as well as the economic aspects. Regarded in this way, we will find that cineplasty has its place as a special measure to meet the needs of special persons rather than as a solution to the problems of all amuutees. HENRY H. KESSLER. Newark, New Jersey.
HÆMOLYTIC DISEASE OF THE NEWBORN SiB,—May I comment on your interesting annotation (April 5), and on Sir Leonard Parsons’s letter (April 19) ? Nomenclature in haematology is notoriously vague ; indeed it does not appear to be clear what each hsematologist means by an erythroblast. May I suggest that instead of " haemolytic disease of the newborn " there be a new classification under the heading " Rhesus diseases of the newborn," to include (i) erythroblastosis or congenital anaemia ; (ii) icterus gravis neonatorum ; and (iii) hydrops foetalis. Such a classification does, I think, agree with present-day knowledge. In (i) the antibody has attacked mainly the haemopoietic system of the child, and the disease is a haemolytic congenital anaemia. In (ii) the liver cells and, either primarily or secondarily, the brain and extrapyramidal cells are attacked by the antibody or antibodies ; this is essentially a toxic condition, unconnected with haemolysis. In (iii), the gravest of the diseases, the antibody has attacked all the internal organs, with the well-known result of stillbirth or an oedematous, peeling, fcetus destined to live only a few hours. In these three conditions it may seem that the maternal antibody, whether single, compound, or incomplete (blocking), may be selective for certain tissues. Regarding treatment, surely Sir Leonard Parsons would not suggest that the logical treatment of a severe case of icterus gravis, where, as often as not, there is no ansemia, is to transfuse with Rh-negative blood " to correct the anaemia." Exsanguination transfusion is no new treatment; many years ago it was practised by Sir John Fraser, in Edinburgh, for the treatment and prevention of shock due to burns. Finally, in respect of mortality, Sir Leonard gives a figure of 27 % for these babies at his clinic since he started to transfuse Rh-negative blood. In my own small series, .since 1942, the mortality is nil, but in view of the
unfortunate incidence of kernicterus I would have welcomed a mortality of more than 27 %. To my mind it is the end-result that matters, not the immediate mortality ; and further careful consideration of children two years after survival of the disease is needed. HENRY THIRD. Nelson, Lanes. CHILD GUIDANCE IN OLD AGE SiR,-The meshes of the net spread by Professor Mackintosh in your issue of May 17 are a little too plainly visible. Chaff will not trap the wary old bird. I appreciate the spirit of mischief that has crept into the latest of his pastoral letters ; but will he tell us, who have changed our occupation at 65, how to recognise that even for the new task our powers have become inadequate and a proper opportunity for ridicule by our loved young ones ? Perhaps, after all, I am enmeshed in his snare ! PHOENIX. ADVICE ON THUNDERSTORMS SIR,-Your note on thunderstorms (May 17, p. 682) interested me. I would like to describe the precautions taken by a family I once knew. To permit fireballs to pass safely through the house without striking off their legs they used to open doors and windows and sit with their feet on the table. These precautions were invariably effective. In addition the mother encouraged her children by the assurance that every flash or bang meant that the storm was a hundred miles farther off. I believe they heard storms raging in New York or Siberia. This assurance was also effective and none ’
broke down under the strain.
G. C. PETHER.
Colchester.
TECHNIQUE OF PROSTATECTOMY
SiR,-The correspondence following the article by Terence Millin1 introducing retropubic- prostaticadenomectomy showed the interest in methods of curing prostatic obstruction. The bulk of prostatectomies are, no doubt, carried out by general surgeons, and the nonurologist has at times to steer his barque into a somewhat ammoniacal breeze and navigate the narrows of the bladder neck. Some of those who do not specialise in urology have not the opportunity or inclination to acquire the special skill called for outside the oldfashioned suprapubic enucleation, the disadvantages of which are the wet condition of the patient, the frequent changes of dressings after operation, the unsightly
Mr.
scar, and sometimes
subsequent ventral hernia. These largely avoided by adopting the well-known surgical principle of draining through an incision separate from the main operative one-a method I have been using for about three years. In the one-stage operation a median incision is made disadvantages
can
a
be
from the pubes to near the umbilicus, the prostate is enucleated through a vertical incision low in the bladder, and the bleeding is controlled by irrigation or packing. With the help of two fingers in the bladder, the peritoneum is stripped as high as possible so that the anterior part of the dome of the bladder as it recedes backwards is laid bare ; a de Pezzer catheter is inserted through a stab-wound in this region, and the hole made watertight by a circular catgut suture ; the catheter is then brought out by a track made through either rectus muscle and sheath and a skin stab, so that it passes obliquely upwards to one or other side, coming out just below the umbilicus. In the two-stage operation, the first stage consists of an incision starting about one inch above the umbilicus over the right rectus muscle and passing downwards and medially Where to about two inches below it and towards the midline. the bladder is not large, the downward extension may have to be greater. The anterosuperior surface of the bladder is laid bare and the de Pezzer catheter inserted as above. This leaves the area immediately abovethe pubes free of adhesions, At the second a virgin field for the actual prostatectomy. stage an incision of the Pfannenstiehl type is preferred ; this is a transverse incision about one inch above the pubes through the skin and rectus aponeuroses, with separation of the rectus muscles. The prostate is removed through a low bladder-incision. Alternately, a vertical incision, inclining to the left as it passes upwards, may be used. 1.
Lancet, 1945, ii, 693.