- Email: [email protected]
SIGNIFICANCE OF HL-A CYTOTOXIC ANTIBODIES IN Rh HÆMOLYTIC DISEASE
1234 THE DISTENDING FORCE IN THE PRODUCTION OF COMMUNICATING SYRINGOMYELIA SiR,-The mechanism and nomenclature of syringomyelia were discussed in The Lancet last year.1-4 While studying syringomyelia 5-9 in connection with percutaneous puncture of the syrinx, we have made pressure recordings within the cyst and also in the subarachnoid space at the same level as the cyst. The pressure and the pulse amplitudes were measured in 10 patients with syringomyelia and 4 patients with cystic spinal-cord tumours. The recordings were made with electromanometric recording equipment, consisting of a pressure transducer (typeEMT 34’, Elema, Stockholm) and an EMT 31 amplifier connected to aMinograph 81 ’ recorder.10" The patients were supine with heads slightly lowered. After a percutaneous puncture with a Westberg needle 11 the pressure in the subarachnoid space was measured. After withdrawal of 2-3 ml. fluid the cyst was punctured and the intracystic pressure was measured. The withdrawal of fluid may have influenced the mean pressure as well as the pulse-pressure in the subarachnoid space. In most instances the measurements showed the pressure and pulse amplitude in the cyst to be above that in the subarachnoid space; the difference was not significant. In 1 case simultaneous measurements were made in the 1. Williams, B. Lancet, 1969, ii, 189. 2. Gardner, W. J. ibid. p. 541. 3. Williams, B. ibid. p. 696. 4. Newton, E. J. ibid. p. 800. 5. Ellertsson, A. B. Acta neurol. scand. 1969, 45, 385. 6. Ellertsson, A. B. ibid. p. 403. 7. Ellertsson, A. B. Diagnosis of Syringomyelia. Stockholm, 1969. 8. Ellertsson, A. B., Greitz, T. Acta neurol. scand. 1969, 45, 418. 9. Greitz, T., Ellertsson, A. B. Acta radiol. Diag. 1969, 8, 310. 10. Gilland, O. Acta neurol. scand. 165, suppl. 13, 75. 11. Westberg, G. Acta radiol., Stockh. 1966, suppl. 252.
cervical subarachnoid space (c4) and in the cistema magna. was no difference between these recordings. In 1 instance simultaneous and differential pressure recordings were made without the removal of any C.S.F. These measurements were made with a differential pressure transducer (’Elema’ prototype); the recording needles were in the subarachnoid space at c3 and in the cyst at c4. It was found that the pressure was higher and the pulse amplitude lower in the cyst than in the subarachnoid space. With Queckenstedt’s manoeuvre the pressure increased first in the subarachnoid space (fig. 1). Within the cyst the initial pressure increase as well as the initial pressure decrease occurred later than in the subarachnoid space. Furthermore, the pressure within the cyst remained at a higher level and persisted for some time after the cessation of the test. These changes were similar with Valsalva’s manoeuvre (fig. 2), the pressure curves showing the same type of time lag between the changes occurring in the C.S.F. and in the cyst. The pressure increase within the cyst seemed, however, to be less pronounced. This last experiment (in which no c.s.F. was removed) was conducted under optimal physiological condition and with the best available equipment and showed an unquestionable increase of the pressure within the cyst following the increase in intracranial venous pressure. These results suggest that the venous-pressure changes postulated by Mr. Williams 1,3 are more important than the arterialpressure changes suggested by Dr. Gardner.2 However, the time relationship between the pressure changes, the c.s.F. pressure rising earlier in the cervical subarachnoid space than in the cyst, indicate that the distension of the syrinx is not due to a defective intracranial drainage of the c.s.F. through the foramen magnum as suggested by Mr. Williams, but rather to an impaired drainage of the cyst. The observed delayed pressure increase in the cyst may form the basis for an intermittent pressure-gradient at its inlet with subsequent displacement of fluid into the cyst. In syringomyelia our experience accords with that of Dr. Gardner in that we have never seen a positive Queckenstedt test, and we argue that a communication exists between the cyst and the C.S.F space. We feel that it is therefore unnecessary to use the differentiating term " communicating
There
syringomyelia
"
as
employed by Mr. Williams.
We thank Research Engineer Sigge Ottosson, of the neurological department, Karolinska sjukhuset, for valuable aid with the measurements.
Fig. 1-Simultaneous
measurements of
pulse amplitude and pressure in C.S.F. and cyst fluid in a case of syringomyelia. The pulse amplitude is greater, the pressure is lower and rises
earlier at the onset of Queckenstedt’s manoeuvre in the subarachnoid space (a) than in cyst (b). Differential measurements (c) during the test show that, after the intial rapid pressure increase in the subarachnoid space, cyst pressure rises more slowly but reaches a higher level and returns more slowly to its original level after the test.
Fig. 2-Same case as in fig. 1. During Valsalva’s manceuvre the results are almost the same as in fig. 1: a, subarachnoid space; b, cyst; c, differential pressure. Again the mean pressure in the cyst remains increased but slightly so after the initial pressure increase.
Department of Neurology, Landspitalinn, Reykjavik, Iceland. Department of Neuroradiology, Karolinska sjukhuset, 10401 Stockholm 60, Sweden.
ÁSGEIR B. ELLERTSSON. TORGNY GREITZ.
SIGNIFICANCE OF HL-A CYTOTOXIC ANTIBODIES IN Rh HÆMOLYTIC DISEASE SIR,-Professor Clarke and his colleagues (April 18, p. 793) draw attention to a report by Moulinier and Mesnier 11 claiming that severe forms of haemolytic disease of the newborn are more common when an Rh-negative mother forms antibodies to the HL-A antigens of her fetal leucocytes in addition to antibodies against the Rh antigen of its redcells. In their own small series, however, they find no support for this, since of 11 women carrying severely affected babies 5 were doubly immunised and 6 were not; but they conclude that a larger series is required before a definite answer can be given. It is now generally agreed that severe Rh hmmolytic disease is unlikely unless Rh antibodies are present at or 12.
Moulinier, J., Mesnier, F. Paper read at the XIIth International Congress of Blood Transfusion, Moscow, 1969.
1235 certain critical titre,13,14 which, by the technique we employ, is 1/20. We have investigated 200 sera containing anti-Rh for cytotoxic HL-A antibodies. The incidence of double immunisation (HL-A and Rh) in 95 women with a titre of anti-Rh below 1/20, few of whom will have a severely affected baby, was 38%, and this does not differ significantly from that found in 105 mothers with a titre of anti-Rh of 1/20 or more, where the incidence of HL-A antibodies was found to be 40%. Of the 105 cases in which the mother’s Rh antibodies were present at a titre of 1/20 or more, 72 have been followed up, and the analysis is presented in the accompanying table. above
a
SEVERITY OF
Rh
HAMOLYTIC DISEASE IN 72
PREGNANCIES*
reduced. This procedure has no effect on the frequency of alpha waves recorded from the opposite side of the head. (3) A step-wise displacement of the eyeball produces a damped train of oscillations, at alpha frequency, of about the same potential as alpha waves. These waves summate when fed into a small fixed-programme averaging computer. Regular step-function inputs synchronise alpha rhythm so that it may be summated. (4) The mean amplitude of alpha waves recorded at the occiput is related (with a high degree of significance) to the magnitude of the corneoretinal potential, as this potential is varied experimentally. Again, the relation holds only for the one eye and the alpha rhythm recorded on the same side of the head. In addition, we find that in trials on groups of (70 or more) subjects a number of factors affect tremor and alpha waves in a similar way. For example, the mean amplitude of both is highly correlated with visual defect, particularly hypermetropia, and also general factors such as fatigue, gamma activation, and various drugs affect both in com-
parable
*Number of
cases
shown in
parentheses
As will be seen, in this series the presence of cytotoxic HL-A antibodies in addition to high-titre anti-Rh has been of no clinical significance in regard to the severity of the disease in the baby. GEOFFREY H. TOVEY National Tissue Typing C. DARKE Reference Laboratory, I. D. FRASER. Bristol BS10 5ND.
ALPHA RHYTHM: AN ARTEFACT? SIR,-May I reply to the interesting points which have been raised as a result of our speculations about alpha waves (May 9, p. 976) ? Dr. Novotny and I first described our hypothesis that alpha waves are due to an interaction between the standing potential across the eye and tremor in the extraocular muscles in 1967. Since then the only evidence put forward which might seem to conflict with this explanation is that it is possible, in some patients, to record alpha waves after both eyes have been enucleated. We knew this before embarking on our experiments, but it is of no help in establishing the validity or otherwise of our theory because in most enucleations the muscle stumps remain and are, indeed, often functional to the extent that the artificial eyes can be moved a bit by the patient. Also, after the globe has been removed, standing potentials can be recorded between the orbital lining and an indifferent electrode. A commonly raised objection to our ideas has been that there are " many alpha rhythms " having different distributions over the scalp, and with differing properties. However, we would expect this in terms of the hypothesis that there are six muscles in each orbit which can generate the rhythm. Each muscle would be expected to produce tremor at a slightly different frequency and with a slightly different distribution of its potential field over the scalp, or within the substance of the brain. I see no reason to modify our views, which are based on the following experimental results: (1) Tremor, having a frequency spectrum identical with that of occipital alpha waves, can be recorded from a strain-gauge applied directly to the cornea. The oscillating displacement of the eyeball, in the plane of its optical axis, is found, on cross-correlation, to be in constant phase relationship with alpha waves. (2) On cooling one orbit the frequency of alpha rhythm recorded from the occipital region of the same side of the head is 13. Tovey, G. H., Valaes, T. Lancet, 1959, ii, 521. 14. Tovey, L. A. D. J. Obstet. Gynœc. Br. Commonw. 1969, 76, 117.
manner.
We would not expect a radically different view on the generation of alpha rhythm in the human electroencephalogram to command universal acceptance at once. I think, however, that our hypothesis is a better explanation of the established facts than any other; moreover, the experiments we have carried out to test this hypothesis have given results which are extremely difficult to explain in terms of any part of current ideas on alpha rhythm. Department of Physiology,
University College London, W.C.1.
O. C. J. LIPPOLD.
L-ASPARAGINASE AND BLASTOGENESIS SIR-A decrease in the blast-transformation ability of lymphocytes in patients given L-asparaginase was noted by McElwain and Hayward.1 However, Astaldi et al.2 reported that in healthy volunteers injection of small doses of the enzyme did not suppress the blastogenic response to phytohxmagglutinin (P.H.A.), although an inhibitory factor was found in the serum. We studied the stimulatory effect of P.H.A. (50 {g. per culture) and staphylococcal filtrate (S.F.) (0.1 ml. per culture) in cultures of lymphocytes obtained from patients treated with L-asparaginase.3 Slight or no inhibitory effect was noted when the patients’ lymphocytes were cultured in newborn-calf serum or normal plasma, but marked inhibition was obtained when the patients’ plasma was used. We report here a follow-up of the alterations in the blasttransformation capacity of lymphocytes obtained from the peripheral blood of a patient with chronic myeloid leukaemia (C.M.L.) before, during, and after treatment with a highly
purified E. coli L-asparaginase (Kyowa Hakko, Kogyo Co., Ltd., Tokyo, Japan). A daily dose of 5000 l.u. (100 LU. per kg.) was injected intravenously for five days. Blast transformation was determined by the uptake of tritiated thymidine.4 Although the inhibitory effect of the enzyme on P.H.A. or s.F. stimulation did not change greatly, the blast-transformation capacity of the lymphocytes obtained from the peripheral blood of this patient during the remission phase (four days after the last injection) was much enhanced. These results support the suggestion of Schulten et al.5 that, immunosuppression is not a continuing effect of L-asparaginase and Astaldi’s interpretation6 that this enzyme does not act only on tumour cells but also on 1. 2. 3. 4. 5. 6.
McElwain, T. J., Hayward, S. K. Lancet, 1969, i, 527. Astaldi, G., Burgio, G. R., Biscatti, G., Astaldi, A., Ferfoglia, L. ibid. 1969, ii, 643. Benezra, D., Pitaro, R., Hochman, A. Unpublished. Benezra, D., Gery, I., Davies, A. M. Proc. Soc. exp. Biol. Med. 1967, 125, 1305. Schulten, H. K., Giraldo, G., Boyse, E. A., Oettgen, H. F. Lancet, 1969, ii, 644. Astaldi, G., Burgio, G. R., Krc, J., Genova, R., Astaldi, A. ibid. 1969, i, 423.
cervical subarachnoid space (c4) and in the cistema magna. was no difference between these recordings. In 1 instance simultaneous and differential pressure recordings were made without the removal of any C.S.F. These measurements were made with a differential pressure transducer (’Elema’ prototype); the recording needles were in the subarachnoid space at c3 and in the cyst at c4. It was found that the pressure was higher and the pulse amplitude lower in the cyst than in the subarachnoid space. With Queckenstedt’s manoeuvre the pressure increased first in the subarachnoid space (fig. 1). Within the cyst the initial pressure increase as well as the initial pressure decrease occurred later than in the subarachnoid space. Furthermore, the pressure within the cyst remained at a higher level and persisted for some time after the cessation of the test. These changes were similar with Valsalva’s manoeuvre (fig. 2), the pressure curves showing the same type of time lag between the changes occurring in the C.S.F. and in the cyst. The pressure increase within the cyst seemed, however, to be less pronounced. This last experiment (in which no c.s.F. was removed) was conducted under optimal physiological condition and with the best available equipment and showed an unquestionable increase of the pressure within the cyst following the increase in intracranial venous pressure. These results suggest that the venous-pressure changes postulated by Mr. Williams 1,3 are more important than the arterialpressure changes suggested by Dr. Gardner.2 However, the time relationship between the pressure changes, the c.s.F. pressure rising earlier in the cervical subarachnoid space than in the cyst, indicate that the distension of the syrinx is not due to a defective intracranial drainage of the c.s.F. through the foramen magnum as suggested by Mr. Williams, but rather to an impaired drainage of the cyst. The observed delayed pressure increase in the cyst may form the basis for an intermittent pressure-gradient at its inlet with subsequent displacement of fluid into the cyst. In syringomyelia our experience accords with that of Dr. Gardner in that we have never seen a positive Queckenstedt test, and we argue that a communication exists between the cyst and the C.S.F space. We feel that it is therefore unnecessary to use the differentiating term " communicating
There
syringomyelia
"
as
employed by Mr. Williams.
We thank Research Engineer Sigge Ottosson, of the neurological department, Karolinska sjukhuset, for valuable aid with the measurements.
Fig. 1-Simultaneous
measurements of
pulse amplitude and pressure in C.S.F. and cyst fluid in a case of syringomyelia. The pulse amplitude is greater, the pressure is lower and rises
earlier at the onset of Queckenstedt’s manoeuvre in the subarachnoid space (a) than in cyst (b). Differential measurements (c) during the test show that, after the intial rapid pressure increase in the subarachnoid space, cyst pressure rises more slowly but reaches a higher level and returns more slowly to its original level after the test.
Fig. 2-Same case as in fig. 1. During Valsalva’s manceuvre the results are almost the same as in fig. 1: a, subarachnoid space; b, cyst; c, differential pressure. Again the mean pressure in the cyst remains increased but slightly so after the initial pressure increase.
Department of Neurology, Landspitalinn, Reykjavik, Iceland. Department of Neuroradiology, Karolinska sjukhuset, 10401 Stockholm 60, Sweden.
ÁSGEIR B. ELLERTSSON. TORGNY GREITZ.
SIGNIFICANCE OF HL-A CYTOTOXIC ANTIBODIES IN Rh HÆMOLYTIC DISEASE SIR,-Professor Clarke and his colleagues (April 18, p. 793) draw attention to a report by Moulinier and Mesnier 11 claiming that severe forms of haemolytic disease of the newborn are more common when an Rh-negative mother forms antibodies to the HL-A antigens of her fetal leucocytes in addition to antibodies against the Rh antigen of its redcells. In their own small series, however, they find no support for this, since of 11 women carrying severely affected babies 5 were doubly immunised and 6 were not; but they conclude that a larger series is required before a definite answer can be given. It is now generally agreed that severe Rh hmmolytic disease is unlikely unless Rh antibodies are present at or 12.
Moulinier, J., Mesnier, F. Paper read at the XIIth International Congress of Blood Transfusion, Moscow, 1969.
1235 certain critical titre,13,14 which, by the technique we employ, is 1/20. We have investigated 200 sera containing anti-Rh for cytotoxic HL-A antibodies. The incidence of double immunisation (HL-A and Rh) in 95 women with a titre of anti-Rh below 1/20, few of whom will have a severely affected baby, was 38%, and this does not differ significantly from that found in 105 mothers with a titre of anti-Rh of 1/20 or more, where the incidence of HL-A antibodies was found to be 40%. Of the 105 cases in which the mother’s Rh antibodies were present at a titre of 1/20 or more, 72 have been followed up, and the analysis is presented in the accompanying table. above
a
SEVERITY OF
Rh
HAMOLYTIC DISEASE IN 72
PREGNANCIES*
reduced. This procedure has no effect on the frequency of alpha waves recorded from the opposite side of the head. (3) A step-wise displacement of the eyeball produces a damped train of oscillations, at alpha frequency, of about the same potential as alpha waves. These waves summate when fed into a small fixed-programme averaging computer. Regular step-function inputs synchronise alpha rhythm so that it may be summated. (4) The mean amplitude of alpha waves recorded at the occiput is related (with a high degree of significance) to the magnitude of the corneoretinal potential, as this potential is varied experimentally. Again, the relation holds only for the one eye and the alpha rhythm recorded on the same side of the head. In addition, we find that in trials on groups of (70 or more) subjects a number of factors affect tremor and alpha waves in a similar way. For example, the mean amplitude of both is highly correlated with visual defect, particularly hypermetropia, and also general factors such as fatigue, gamma activation, and various drugs affect both in com-
parable
*Number of
cases
shown in
parentheses
As will be seen, in this series the presence of cytotoxic HL-A antibodies in addition to high-titre anti-Rh has been of no clinical significance in regard to the severity of the disease in the baby. GEOFFREY H. TOVEY National Tissue Typing C. DARKE Reference Laboratory, I. D. FRASER. Bristol BS10 5ND.
ALPHA RHYTHM: AN ARTEFACT? SIR,-May I reply to the interesting points which have been raised as a result of our speculations about alpha waves (May 9, p. 976) ? Dr. Novotny and I first described our hypothesis that alpha waves are due to an interaction between the standing potential across the eye and tremor in the extraocular muscles in 1967. Since then the only evidence put forward which might seem to conflict with this explanation is that it is possible, in some patients, to record alpha waves after both eyes have been enucleated. We knew this before embarking on our experiments, but it is of no help in establishing the validity or otherwise of our theory because in most enucleations the muscle stumps remain and are, indeed, often functional to the extent that the artificial eyes can be moved a bit by the patient. Also, after the globe has been removed, standing potentials can be recorded between the orbital lining and an indifferent electrode. A commonly raised objection to our ideas has been that there are " many alpha rhythms " having different distributions over the scalp, and with differing properties. However, we would expect this in terms of the hypothesis that there are six muscles in each orbit which can generate the rhythm. Each muscle would be expected to produce tremor at a slightly different frequency and with a slightly different distribution of its potential field over the scalp, or within the substance of the brain. I see no reason to modify our views, which are based on the following experimental results: (1) Tremor, having a frequency spectrum identical with that of occipital alpha waves, can be recorded from a strain-gauge applied directly to the cornea. The oscillating displacement of the eyeball, in the plane of its optical axis, is found, on cross-correlation, to be in constant phase relationship with alpha waves. (2) On cooling one orbit the frequency of alpha rhythm recorded from the occipital region of the same side of the head is 13. Tovey, G. H., Valaes, T. Lancet, 1959, ii, 521. 14. Tovey, L. A. D. J. Obstet. Gynœc. Br. Commonw. 1969, 76, 117.
manner.
We would not expect a radically different view on the generation of alpha rhythm in the human electroencephalogram to command universal acceptance at once. I think, however, that our hypothesis is a better explanation of the established facts than any other; moreover, the experiments we have carried out to test this hypothesis have given results which are extremely difficult to explain in terms of any part of current ideas on alpha rhythm. Department of Physiology,
University College London, W.C.1.
O. C. J. LIPPOLD.
L-ASPARAGINASE AND BLASTOGENESIS SIR-A decrease in the blast-transformation ability of lymphocytes in patients given L-asparaginase was noted by McElwain and Hayward.1 However, Astaldi et al.2 reported that in healthy volunteers injection of small doses of the enzyme did not suppress the blastogenic response to phytohxmagglutinin (P.H.A.), although an inhibitory factor was found in the serum. We studied the stimulatory effect of P.H.A. (50 {g. per culture) and staphylococcal filtrate (S.F.) (0.1 ml. per culture) in cultures of lymphocytes obtained from patients treated with L-asparaginase.3 Slight or no inhibitory effect was noted when the patients’ lymphocytes were cultured in newborn-calf serum or normal plasma, but marked inhibition was obtained when the patients’ plasma was used. We report here a follow-up of the alterations in the blasttransformation capacity of lymphocytes obtained from the peripheral blood of a patient with chronic myeloid leukaemia (C.M.L.) before, during, and after treatment with a highly
purified E. coli L-asparaginase (Kyowa Hakko, Kogyo Co., Ltd., Tokyo, Japan). A daily dose of 5000 l.u. (100 LU. per kg.) was injected intravenously for five days. Blast transformation was determined by the uptake of tritiated thymidine.4 Although the inhibitory effect of the enzyme on P.H.A. or s.F. stimulation did not change greatly, the blast-transformation capacity of the lymphocytes obtained from the peripheral blood of this patient during the remission phase (four days after the last injection) was much enhanced. These results support the suggestion of Schulten et al.5 that, immunosuppression is not a continuing effect of L-asparaginase and Astaldi’s interpretation6 that this enzyme does not act only on tumour cells but also on 1. 2. 3. 4. 5. 6.
McElwain, T. J., Hayward, S. K. Lancet, 1969, i, 527. Astaldi, G., Burgio, G. R., Biscatti, G., Astaldi, A., Ferfoglia, L. ibid. 1969, ii, 643. Benezra, D., Pitaro, R., Hochman, A. Unpublished. Benezra, D., Gery, I., Davies, A. M. Proc. Soc. exp. Biol. Med. 1967, 125, 1305. Schulten, H. K., Giraldo, G., Boyse, E. A., Oettgen, H. F. Lancet, 1969, ii, 644. Astaldi, G., Burgio, G. R., Krc, J., Genova, R., Astaldi, A. ibid. 1969, i, 423.