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HÆMOLYTIC DISEASE OF THE NEWBORN DUE TO ANTI-A ANTIBODIES
173
corpuscular volume 97 c[J.; mean corpuscular haemoglobin concentration 30% ; white cells 7500 per c.mm. (neutrophils 75%, lymphocytes 18-5, monocytes 6-5%). It is considered that this case was one of thyrotropic exophthalmos with chronic myopathy. The myopathy and exophthalmos seemed to have developed in parallel. The relapsing nature of the myopathy is of interest, and does seem to support its thyrotropic setiology—associated
possibly with variations in thyroid-stimulating hormone.
the
rate
of release of
I wish to thank Dr. R. E. Horsfall for permission to report this case. RAYMOND C. GLEDHILL. Victoria Hospital, Blackpool.
ANTI-HISTAMINE DRUGS IN THE TREATMENT OF BURNS SIR,-A few days before I read the letter of May 28 from Dr. Shubsachs, my son-13 years old and very fair-swam for some hours in a pond exposed to the sun. When he came home he looked very ill, and he was red all over. He had no fever, but the dermatitis I applied ’Inotyol’ was very severe and painful. ointment followed by free dusting with talcum powder. The burning was partly relieved but he was unable to sleep at night. I gave him one capsule of ’Benadryl’ (50 mg.) ; he felt better and was sound asleep in about half an hour. He took three capsules daily, and dusted himself several times a day with talcum powder. On the fourth day he was cured completely and was able to attend school again. This confirms Dr. Shubsachs’s opinion that antihistamines may have an important role in the treatment of burns and even other inflammations of the skin. DJAMIL FAÏK TUTUNJI Amman,
The Jordan.
Under-Secretary of State for Health.
HÆMOLYTIC DISEASE OF THE NEWBORN DUE TO ANTI-A ANTIBODIES SiR,-In your issue of June 25 Miss Boorman and her colleagues reported two cases of haemolytic disease of the newborn due to anti-A. They pointed out that the most convincing evidence of the action of anti-A in such cases is the demonstration that A cells, but not 0 cells, are rapidly destroyed after transfusion. In one of their cases they succeeded in securing evidence of the rapid elimination of A cells, though they could not obtain serial quantitative data. A little while ago we obtained satisfactory estimates of the survival of A and 0 cells in a similar case, and this may be an opportune moment to record them. The mother had had one previous pregnancy, resulting in healthy child (later shown to be group AI), Her second infant was born two years later. Before its birth the midwife noticed that the liquor amnii was very yellow and at birth the infant’s umbilical cord was yellow and the vernix caseosa orange. A sample of blood was obtained from the umbilical vein immediately the child was born, and this had a haematocrit of 30% and a haemoglobin concentration of 10 g. per 100 ml. (These values are only about 60% of the average normal and are far below the normal range.) The serum-bilirubin concentration was 3 mg. per 100 ml.-just above normal limits for cord blood ; and a blood film showed a considerable excess of nucleated red cells. The direct Coombs test was weakly
a
positive.
The results of
blood-group
tests
were as
follows :
7M/aM,<.—Ai (secretor), MN, CDe/eDE ; its serum did not agglutinate A or B cells suspended in saline. Mother.-O, MN, CDe/CDe ; her serum haemolysed A cells but not B cells ; the serum had an iso-agglutinin titre of 1/1000 against r11 cells and of 1/128 against B cells. The titres were no higher when the cells were suspended in 30% albumin and the serum was diluted in albumin than when the titrations were done in salme. The serum did not agglutinate, or sensitise to an anti-globulin serum, cells of types CDe/cDE
or
cde/cde.
The bloods of the mother and infant were also tested by Dr. Sylvia Lawler of the M.R.C. Blood Group Research Unit who found that both were P+, S-, Lewis+, and Kelt— ; the mother was Lutheran-negative and the infant Lutheranpositive, but the mother’s serum did not contain antiLutheran. By 16 hours after birth the infant’s haemoglobin concentration had risen to 16-4 g. per 100 ml., doubtless mainly owing to the placental transfer of blood ; the serum-bilirubin level was 5-5 mg. per 100 ml. and the reticulocyte-count 8-6%. The infant was transfused via the umbilical vein with about 35 ml. of washed, packed 0, N, CDe/CDe cells and 40 ml. of With very potent washed, packed At, M, cde/cde cells. anti-Rh and anti-M sera, counts could now be made of the survival of the At and the 0 cells. Venous samples were taken from scalp veins on succeeding days and the estimates were : Unagglutinated erythrocytes * per c.mm.
Total Hb
Time after, transfusion 0 cells (with
li
10 min.I ,
1 4 5 6 11 20 47
day days days days days days days
’
I z
(with anti-Rh)
4000
4000
853,000 873,000 880,000 932,000
1,030,000 968,000 545,000 396,000 352,000 216,000 234,000 113,000
Before
901,000
935,000 765,000 566,000
* Each estimate based
on a
(g. per
100 ml.)
A cells
anti-M)
I
16-4 18.9 19.4 18-4 17-7 17-2 15-5 14-1 12-6
count of approximately 3000 cells.
Thus during the six days after transfusion the concentration of transfused A cells fell to about 35% of the initial value. By contrast, during the same period the count of 0 cells actually rose slightly, probably because of a readjustment of blood-volume. Evidently the survival of the 0 cells was normal and that of the A cells grossly reduced. The increased rate of elimination of A cells came to a stop between 6 and 11 days after birth ; and by the end of the first week of life the reticulocyte-count had fallen to 1-5%. The direct Coombs test remained definitely positive for 48 hours after birth, was doubtfully positive 5 days after birth, and thereafter was negative.
The infant’s
entirelv satisfactorv. P. L. MOLLISON Unit,Department of Obstetrics, MARIE CUTBUSH. Postgraduate Medical School of London. Droaress was
M.R.C. Blood Transfusion Research
EXCHANGE OF DOCTORS WITH THE U.S.A. SIR,—Before the war there were some schemes in action for the exchange of doctors between hospitals in this country and the U.S.A. There is now a more widespread desire by doctors in this country to visit the U.S.A. This may often be facilitated by arranging for a regular exchange of doctors between medical schools and hospitals in the two countries. There seems to be some fear that making such an arrangement for an American doctor to work in a hospital here infringes the Acts governing medical practice. This is not the case, for by section 8 of the Medical Practitioners and Pharmacists Act, 1947, Parliament has made provision for the admission to the Medical Register of Commonwealth and foreign practitioners temporarily in the employ of hospitals in this country. If a hospital is prepared to offer a postgraduate post to a qualified practitioner who is not registered here, it is desirable both for him and for the hospital that he should have the status of a registered medical practitioner as the holder of that post ; and section 8 enables him to become temporarily registered for that purpose. The procedure for temporary registration under the section is quite simple, and it is only necessary to add that a practitioner who is not a British subject must, of course, as a first step obtain permission from the Home Office to enter and to remain in the U.K. in order to do postgraduate work. R. C. MAC KEITH Guy’s Hospital, London, S.E.1.
Hon. Secretary, The Horse Shoe Club.
corpuscular volume 97 c[J.; mean corpuscular haemoglobin concentration 30% ; white cells 7500 per c.mm. (neutrophils 75%, lymphocytes 18-5, monocytes 6-5%). It is considered that this case was one of thyrotropic exophthalmos with chronic myopathy. The myopathy and exophthalmos seemed to have developed in parallel. The relapsing nature of the myopathy is of interest, and does seem to support its thyrotropic setiology—associated
possibly with variations in thyroid-stimulating hormone.
the
rate
of release of
I wish to thank Dr. R. E. Horsfall for permission to report this case. RAYMOND C. GLEDHILL. Victoria Hospital, Blackpool.
ANTI-HISTAMINE DRUGS IN THE TREATMENT OF BURNS SIR,-A few days before I read the letter of May 28 from Dr. Shubsachs, my son-13 years old and very fair-swam for some hours in a pond exposed to the sun. When he came home he looked very ill, and he was red all over. He had no fever, but the dermatitis I applied ’Inotyol’ was very severe and painful. ointment followed by free dusting with talcum powder. The burning was partly relieved but he was unable to sleep at night. I gave him one capsule of ’Benadryl’ (50 mg.) ; he felt better and was sound asleep in about half an hour. He took three capsules daily, and dusted himself several times a day with talcum powder. On the fourth day he was cured completely and was able to attend school again. This confirms Dr. Shubsachs’s opinion that antihistamines may have an important role in the treatment of burns and even other inflammations of the skin. DJAMIL FAÏK TUTUNJI Amman,
The Jordan.
Under-Secretary of State for Health.
HÆMOLYTIC DISEASE OF THE NEWBORN DUE TO ANTI-A ANTIBODIES SiR,-In your issue of June 25 Miss Boorman and her colleagues reported two cases of haemolytic disease of the newborn due to anti-A. They pointed out that the most convincing evidence of the action of anti-A in such cases is the demonstration that A cells, but not 0 cells, are rapidly destroyed after transfusion. In one of their cases they succeeded in securing evidence of the rapid elimination of A cells, though they could not obtain serial quantitative data. A little while ago we obtained satisfactory estimates of the survival of A and 0 cells in a similar case, and this may be an opportune moment to record them. The mother had had one previous pregnancy, resulting in healthy child (later shown to be group AI), Her second infant was born two years later. Before its birth the midwife noticed that the liquor amnii was very yellow and at birth the infant’s umbilical cord was yellow and the vernix caseosa orange. A sample of blood was obtained from the umbilical vein immediately the child was born, and this had a haematocrit of 30% and a haemoglobin concentration of 10 g. per 100 ml. (These values are only about 60% of the average normal and are far below the normal range.) The serum-bilirubin concentration was 3 mg. per 100 ml.-just above normal limits for cord blood ; and a blood film showed a considerable excess of nucleated red cells. The direct Coombs test was weakly
a
positive.
The results of
blood-group
tests
were as
follows :
7M/aM,<.—Ai (secretor), MN, CDe/eDE ; its serum did not agglutinate A or B cells suspended in saline. Mother.-O, MN, CDe/CDe ; her serum haemolysed A cells but not B cells ; the serum had an iso-agglutinin titre of 1/1000 against r11 cells and of 1/128 against B cells. The titres were no higher when the cells were suspended in 30% albumin and the serum was diluted in albumin than when the titrations were done in salme. The serum did not agglutinate, or sensitise to an anti-globulin serum, cells of types CDe/cDE
or
cde/cde.
The bloods of the mother and infant were also tested by Dr. Sylvia Lawler of the M.R.C. Blood Group Research Unit who found that both were P+, S-, Lewis+, and Kelt— ; the mother was Lutheran-negative and the infant Lutheranpositive, but the mother’s serum did not contain antiLutheran. By 16 hours after birth the infant’s haemoglobin concentration had risen to 16-4 g. per 100 ml., doubtless mainly owing to the placental transfer of blood ; the serum-bilirubin level was 5-5 mg. per 100 ml. and the reticulocyte-count 8-6%. The infant was transfused via the umbilical vein with about 35 ml. of washed, packed 0, N, CDe/CDe cells and 40 ml. of With very potent washed, packed At, M, cde/cde cells. anti-Rh and anti-M sera, counts could now be made of the survival of the At and the 0 cells. Venous samples were taken from scalp veins on succeeding days and the estimates were : Unagglutinated erythrocytes * per c.mm.
Total Hb
Time after, transfusion 0 cells (with
li
10 min.I ,
1 4 5 6 11 20 47
day days days days days days days
’
I z
(with anti-Rh)
4000
4000
853,000 873,000 880,000 932,000
1,030,000 968,000 545,000 396,000 352,000 216,000 234,000 113,000
Before
901,000
935,000 765,000 566,000
* Each estimate based
on a
(g. per
100 ml.)
A cells
anti-M)
I
16-4 18.9 19.4 18-4 17-7 17-2 15-5 14-1 12-6
count of approximately 3000 cells.
Thus during the six days after transfusion the concentration of transfused A cells fell to about 35% of the initial value. By contrast, during the same period the count of 0 cells actually rose slightly, probably because of a readjustment of blood-volume. Evidently the survival of the 0 cells was normal and that of the A cells grossly reduced. The increased rate of elimination of A cells came to a stop between 6 and 11 days after birth ; and by the end of the first week of life the reticulocyte-count had fallen to 1-5%. The direct Coombs test remained definitely positive for 48 hours after birth, was doubtfully positive 5 days after birth, and thereafter was negative.
The infant’s
entirelv satisfactorv. P. L. MOLLISON Unit,Department of Obstetrics, MARIE CUTBUSH. Postgraduate Medical School of London. Droaress was
M.R.C. Blood Transfusion Research
EXCHANGE OF DOCTORS WITH THE U.S.A. SIR,—Before the war there were some schemes in action for the exchange of doctors between hospitals in this country and the U.S.A. There is now a more widespread desire by doctors in this country to visit the U.S.A. This may often be facilitated by arranging for a regular exchange of doctors between medical schools and hospitals in the two countries. There seems to be some fear that making such an arrangement for an American doctor to work in a hospital here infringes the Acts governing medical practice. This is not the case, for by section 8 of the Medical Practitioners and Pharmacists Act, 1947, Parliament has made provision for the admission to the Medical Register of Commonwealth and foreign practitioners temporarily in the employ of hospitals in this country. If a hospital is prepared to offer a postgraduate post to a qualified practitioner who is not registered here, it is desirable both for him and for the hospital that he should have the status of a registered medical practitioner as the holder of that post ; and section 8 enables him to become temporarily registered for that purpose. The procedure for temporary registration under the section is quite simple, and it is only necessary to add that a practitioner who is not a British subject must, of course, as a first step obtain permission from the Home Office to enter and to remain in the U.K. in order to do postgraduate work. R. C. MAC KEITH Guy’s Hospital, London, S.E.1.
Hon. Secretary, The Horse Shoe Club.