SKIN-GRAFTING OF FINGERTIP INJURIES

1003 leukxmia death-rates for non-county hospitals apparent in the

accompanying table is notable; the leukaemia death-rate for children born in hospitals with neonatal death-rates over 21 per 1000 was nearly twice that for hospitals with neonatal deathrates less than 13 per 1000 (30-8 v. 16-7 per 100,000). High neonatal death-rates are associated with increasing birth-order, extremes of maternal age,3and low socioeconomic conditions.5 The Negro ethnic group also has a high neonatal mortality-rate,4 5 which to some extent is confounded with prematurity and socioeconomic characteristics. In contrast,8 high childhood leukaemia risks are associated with Caucasians, high socioeconomic condition,7 and, with lesser consistency and magnitude, decreasing birth-order and increasing maternal

ague. 68 Thus, with the exception of maternal age, characteristics showing high neonatal mortality are opposite to those associated with high childhood leukaemia risks. It is surprising, therefore, to observe a positive association between neonatal and leukaemia death-rates. We intend to extend the observations in California to other birth-years, and to ages 0-10 years, and to adjust for maternal age, sex, and race. It is hoped that other investigators will determine whether or not results similar to those reported here are observed in other populations. This work was supported by U.S. Public Health Service grant CA 05924 of the National Cancer Institute. We are indebted to Dr. Robert D. Grove, chief, division of vital statistics, National Center of Health Statistics, for identifying 4 cases who died of leukaemia outside California, and the Bureau of Maternal and Child Health, California State Department of Public Health, for the data on neonatal deaths by hospital of birth. California Cancer Field Research Program, State of California

Department of Public Health, Berkeley, California 94704

MELVILLE R. KLAUBER EDWIN W. JACKSON.

PHYTOHÆMAGGLUTININ IN APLASTIC ANÆMIA SIR,-The efficacy of phytohsemagglutinin (P.H.A.) for the treatment of aplastic anasmia has been under discussion ever since the first report of Humble 9 in 1964. Conflicting results have been reported by a number of investigators. 9-12 We recently attempted to treat with P.H.A. a 56-year-old man, who had

aplastic anxmia in conjunction with a benign Since thymectomy and a series of other therapeutic measures did not lead to improvement, we undertook treatment by the method of Astaldi et al.ll Lymphocytes from the peripheral venous blood of the patient were cultivated under aseptic conditions in ’T.C. 199 ’ (Difco) containing P.H.A. After 48 hours 80-90% of the in-vitro cell-population consisted of pyroninophilic blast cells. These cells were implanted in the patient’s sternal bone-marrow. A total of eleven such implantations were done at intervals of 7 days. Each implant contained 4 x 107 to 5 x 10’ cells. Throughout the period of treatment, and for several weeks afterwards, no evidence of improved erythropoiesis was noted. There were no apparent adverse side-effects. Several weeks after the final implantation, the patient developed severe hepatitis, which was probably a consequence of repeated blood-transfusions. y-globulin was administered, severe

thymoma.

3. Newcombe, H. B. Eugen. Q. 1965, 12, 90. 4. Meyer, A., Marks, R. Hum. Biol. 1954,26, 143. 5. Abramowicz, M., Kass, E. H. New Engl. J. Med. 1966, 275, 878. 6. Stark, C. R., Oleinick, A. J. natn. Cancer Inst. 1966, 37, 369. 7. Githens, J. H., Elliot, F. E., Saunders, L. H. Publ. Hlth. Rep., Wash. 1965, 80, 573. 8. MacMahon, B., Newell, V. A. J. natn. Cancer Inst. 1962, 28, 231. 9. Humble, J. G. Lancet, 1964, i, 1345. 10. Baker, G. P., Oliver, R. A. M. ibid. 1965, i, 438. Gruenwald, H., Taub, R. N., Wong, F. M., Kiossoglou, K. A., Dameshek, W. ibid.

p. 962. 11. 12.

Astaldi, G., Airò, R., Sauli, S., Costa, G. ibid. p. 1070. Mehra, S. K., Davies, D. M., Bell, S. M. ibid. p. 1164. Gurling, K. J., Leonard, B. J. ibid. 1965, ii, 794. Papac, R. J. ibid. 1966, i, 63. Buschor, O. R., von Deschwanden, P. L. ibid. p. 770. Fleming, A. F., Osunkoya, B. O., Antia, A. U. ibid. 1966, ii, 338. Aksoy, M., Erdem, Ş., Dinçol, K. ibid. p. 1464. Hayes, D. M., Spurr, G. L. Blood, 1966, 27, 78.

shortly thereafter a slight but definite rise in erythropoietic activity was detected, both in the peripheral blood (raised reticulocyte-count) and in the bone-marrow. It is impossible and

determine the exact cause of this erythropoietic response, but its temporal relation to the administration of y-globulin is suggestive. The patient succumbed to complications of the

to

hepatitis. 1st

University Medical Clinic, Hamburg-Eppendorf, Germany.

H. G. THIELE P. VON WICHERT.

SKIN-GRAFTING OF FINGERTIP INJURIES p. 705) will be read with interest in most of the accident centres in this country. The problem he discusses is a common one for many accident officers, but the statement that " Accident officers should be encouraged to carry out this simple operation [partial-thickness skin-grafting] whenever digital skin cover is required " should be questioned for various reasons. In the introduction, mentioning the various forms of treatment, the cross-palmar flap and the pinch-graft to cover a small area of digital skin have been omitted. They have their own place in suitable circumstances. Partial-thickness grafts usually contract, and so do not prove ideal for cosmetic or professional reasons. To my mind, opinion should be well-balanced in all these injuries without being biased in favour of one form of graft or another. From my experience in this country in the past few years, the selection of the type of graft should be based on the following factors:

SIR,-Dr. Salaman’s article (April 1,

Extent of injury.-Where there is avulsion of nail and where the distal phalanx is fractured, any type of graft will X-ray examination of every fingertip is essential.

pulp, not

or

heal.

Haemorrhage.-Whether or not haemostasis can be achieved locally by ligating the bleeding vessels, it is essential for full-thickness grafts; partial-thickness skin-grafts may take even in absence of complete hoemostasis. Age of patient and of wound.-Young patients with a history of injury within 6-8 hours do very well with full-thickness grafts; others, where there is likelihood of infection and slow healing, benefit from partial-thickness grafts. Occupation.-A labourer’s finger is exposed to friction and trauma and one should consider whether better results can be achieved by grafting or by hemiphalangectomy.

Finally, as in all surgical procedures, asepsis are essential in every graft.

atraumatic

technique

and

General Surgical Unit, General Hospital, Park Road North, Birkenhead, Cheshire.

A. HAIKHAN.

SIR,-While I agree with Dr. Loring Webb (April 22, 902) that split-skin grafts can be very satisfactorily held with Steri-Strips ’, may I suggest great caution before grafting a fingertip without a preliminary finger-block. Many finger injuries, including apparently simple lacerations as well as loss of the tip, are in fact crush injuries, and need careful debridement before suturing or grafting. It needs experience of these injuries and some knowledge of the mechanism causing them to decide which can safely be treated without local anaesthetic. Of those requiring grafts, the only ones suitable for the simpler method would be those where pulp, but not bone, had been sliced off cleanly, and certain friction bums. When in any doubt an adequate local anaesthetic should be used before the final cleaning and assessment of finger injuries. Often the extent of the damage cannot be judged until this is done, and may well be greater than expected. Far too many finger injurp. ’

ies become infected after treatment and cause unnecessary disability because they are considered trivial when first seen. CLARA ZILAHI.