TREATMENT OF ASPHYXIA NEONATORUM

1214 A CLINICAL STUDY OF SURGICAL SHOCK

sensitised to normal rabbit serum the resulting lesions in the next 24 hours resembled the Arthus reaction. After 24 hours, however, typical dermatotoxic dermatitis appeared which persisted, according to the amount of injected serum, as in non-sensitised guineapigs. In further experiments we failed to confirm the findings of ances. Wilhelmj et al. on the appearance of autosensitisation in the There are three aspects of the treatment of shock which require further comment. Firstly, poor peripheral perfusion.guineapig to its own skin. 7 These results are similar to those obtained by Moschos et al.’ leads to metabolic acidosis, and this often requires large Department of Allergy, EDWARD RUDZKI (40-160 mEq.) doses of sodium bicarbonate until blood-flow Karolinska Institute, ÅKE NILZÉN. is improved. Secondly, there is no question that at the present Stockholm 60. time the central venous pressure is the most accurate index of the adequacy of the circulating blood-volume and cardiac output. I would not be happy, however, unless this were TREATMENT OF ASPHYXIA NEONATORUM measured through a large polyethylene catheter inserted I the vein. believe SIR,-The trial of hyperbaric oxygen and intermittent posiFurther, through cephalic or external jugular that Dr. McGowan and Dr. Walters take too static a view of tive-pressure ventilation (i.P.P.v.) in asphyxia neonatorum, the significance of the central-venous-pressure reading. The reported by Professor Hutchison and his colleagues (April 30), demonstrates once again that most infants who are resuscitated measurement may vary over a range of 4-8 cm. during a given at birth are in primary apncea-that is to say, they have not yet treatment period; I have repeatedly seen a rise in response to reached the last gasp (in the absence of effective resuscitation). rapid intravenous infusion of fluids, to be followed within At least 210, perhaps more, of the 218 infants they studied fall minutes by a gradual fall to normal levels, thus providing a dynamic index of changes in cardiac output and circulating into that category. This is why many methods of resuscitation, even those which on subsequent investigation are discovered blood-volume.’Thirdly, contrary to previous teaching, I have to be ill-founded (e.g., gastric oxygen), are at first claimed to found rapid digitalisation extremely effective in improving be effective. cardiac output as measured by decreased central venous presTwo questions arise. Firstly, is one method better than sure, increased urine output, and improved skin colour. in that small group of infants in secondary apncea (i.e., another additional these three methods of I feel that Using approach, I have met with more success in the management of this beyond the last gasp) who are at greatest risk ? The observations of Professor Hutchison and his colleagues do not answer difficult clinical situation. this because their numbers are too small, but the evidence Mount Sinai Hospital Services, City Hospital Center at Elmhurst, from animal work is clear, and shows that i.P.P.v. is always ADOLF SINGER. York 11373. Elmhurst, New more effective than hyperbaric oxygen.8 This was particularly so in animals with unexpanded lungs, all of which died on being exposed to hyperbaric oxygen. Morison 9 doubted whether i.P.P.v. can expand the atelectatic lungs of an infant ANTIBODIES TO GUINEAPIG SKIN-ANTIGENS the last gasp, and Professor Hutchison and his obtained from SiR,—We antigens guineapig skin by the who is beyond colleagues have shared that doubt without testing its validity. method of Wilhelmj et a1.5 The average yield from 1 g. of skin It is invalid. The lungs of a stillborn infant can be expanded was 50 mg. of protein. Immunisation of rabbits with these Both mature and premature foetal rhesus monkeys by antigens resulted in production of dermatotoxic serum contain- havei.P.P.v. been resuscitated in this way, even though successfully ing antibodies reacting with homologous guineapig suspension some had severe metabolic acidosis on delivery by already in hxniagglutination and precipitation reactions. Immunosection (as a result of various conditions, including electrophoresis (by Dr. R. Norberg, King Gustaf V Research csesarean the stress of preparation for delivery, combined with maternal Institute, Stockholm) showed the presence of the antibodies, lung disease, placental infarction, or placenta praevia) and were antialbumin and anti--globulin. The strongest dermatotoxic then deliberately asphyxiated for several minutes beyond the serum had a hxmagglutination titre of 1/20,000 against the skin suspension. In each particular serum there was some correla- last gasp. Secondly, is one method better than another in primary tion between the hxmagglutination titre and the weakest apnoea ? Professor Hutchison and his colleagues describe their dilution causing dermatotoxic effects on guineapig skin. investigation as a controlled trial, but it was controlled only in Rabbit anti-guineapig-skin sera did not produce any visible the sense that it was an alternate case treatment of a condition changes in the skin of rats, rabbits, or mice. whose severity is highly variable. They assessed the severity In guineapigs injected intradermally with dermatotoxic sera, of asphyxia by the Apgar score, which is poor at differentiating swelling and erythema appeared after 2-4 hours. The diameter severe degrees of asphyxia-umbilical arterial pH on delivery of erythema was directly proportional to the amount of introa better index. Their failure to observe a significant difference is duced antibodies. In 4-6 hours pronounced hxmorrhagic between the two methods of treatment does not mean that lesions developed. In 24 hours necrosis appeared in the central such a difference does not exist. The use of statistics does not part of the lesions, which mostly ulcerated in 2-3 days. The compensate for a heterogeneous population unless the trial is ulcers had sharp edges, were superficial, and healed with large and well planned in other ways. We need more informaWhen no ulceration infiltration for occurred, scarring. persisted tion about the time-interval from the decision to resuscitate 6 1-2 weeks after the injection. No late Kay-type reactions until cardiac acceleration and the first gasp. It is not sufficient were observed. Preliminary immunofluorescent investigations to judge the efficacy of resuscitation solely by survival. (by Dr. B. Lagerlof of the department of pathology of this Finally, Professor Hutchison and his colleagues say: " It is the institute) showed disappearance of control normal rabbit- understandable that the physiologist writing on the subject of y-globulins from guineapig skin in 24 hours, whereas y-globu- neonatal resuscitation should insist on preliminary animal lins of dermatotoxic sera persisted in connective tissue for at if the issue were one of prejudice. It is experimentation "-as least 3 days and had no affinity for blood-vessels or epidermis. an issue of public policy. No-one would use a new drug without When dermatotoxic sera were injected into the skin of guineapreceding trials in animal species and under conditions appro1. Mansberger, A. R., Ollodart, R. M., Attar, S., Cowley, A. R., Buxton, R. W. Ann. Surg. 1965, 161, 955, priate for the purpose. It is especially difficult to design and 2. Hamit, H. F. Surgery, Gynec. Obstet. 1965, 119, 835. execute trials in newborn infants. Many would have doubts 3. Hopkins, R. W., Sabga, G., Penn, I., Simeone, F. A. J. Am. med. Ass. 7. Moschos, D. T., Rosenthal, S. A., Schroeder, H. Archs Derm. 1964, 1965, 191, 731.

SIR,-The article by Dr. McGowan and Dr. (March 19) gives an excellent account of the clinical of shock, and one would generally agree with most statements about the accompanying haemodynamic

-

pigs previously

Walters features of their disturb-

,

-

’

4. 5.

Weil, M. H., Shubin, H., Rosoff, L. ibid. 1965, 192, 668. Wilhelmj, Ch. M., Kierland, R. R., Owen, Ch. A. Archs Derm. 1962, 86, 161. 6. Kay, C. F. J. exp. Med. 1940, 72, 559.

90, 620. Campbell, A. G. M., Cross, K. W., Dawes, G. S., Hyman, J. Pediat. 1966, 68, 153. 9. Morison, J. E. Foetal and Neonatal Pathology. London, 1963. 8.

A. I.

1215

waiting

about

4-5 minutes from birth

permanent brain damage

asphyxia in newly

to treatment

in babies;

after

only 7-8 minutes total monkeys, though it cannot always

occurs

delivered be detected by clinical examination. The basic assumption that only oxygen is required for resuscitation is false. It is only in the early stages of asphyxia that oxygen lack is the crucial factor-ultimately it is the fall in pH which damages the brain and stops the heart (in that order). So the most urgent thing is not to supply oxygen to the lungs but to ventilate them. Cardiovascular Research Institute, School of Medicine, San Francisco Medical Center,

University of California,

G. S. DAWES.

California 94122.

EXCHANGE-TRANSFUSION APPARATUS like pets-one becomes very fond of one’s own and will not change it. I am prompted by the letter of Dr. Simmons and Dr. Ata (April 2) to describe my own pet-a disposable apparatus for a gravity (drip) exchange-transfusion system.! It is a little odd, when in good paediatric practice we insist that simple transfusions to infants should always be given by drip, that we continue to use the " push " technique for the giving part of the exchangetransfusion cycle. There is no advantage in doing so, while the disadvantages are obvious. Once we accept this we arrive at a much safer and simpler procedure.!

SIR,-Exchange-transfusion apparatuses

accompanying figure shows the complete assembly, use at the newborn unit of this hospital, which many improvements over the assembly previously

currently in offers

described.1 1. The whole apparatus is

disposable:

it includes

a

’Metriset’

administration set, special four-way valve (’Pharmaseal’ four-way

valve, as modified by the makers to our specifications), and disposable syringe and catheters. 2. There is only one valve and only two positions for the whole procedure: in position i, blood is aspirated from the patient; in position n, the donor-blood, in measured quantities of 10 or 20 ml., 1.

Valaes,

T.

The simplicity of the procedure with this assembly is a great contribution towards its safety. Over 600 exchange transfusions have been performed by the drip method in our unit without a single accident. Moreover 25 young residents have performed these exchanges single-handed and after they have been shown the method only 2-3 times. It seems an extravagant claim, but on several occasions one operator has performed two exchange transfusions simultaneously quite easily. The various components of the assembly seal Laboratories and Don Baxter, Inc.

Queen Anna-Maria Institute of Child Health, Aghia Sophia Children’s Hospital, Athens 609.

are

supplied by

Pharma-

T. VALAES.

are

Disposable exchange-transfusion apparatus. The

into the patient by gravity and at the desired rate, while the aspirated patient-blood is emptied to a waste receiver. 3. The special rubber-capped nozzle of the four-way valve allows drugs to be given to the patient without disconnecting the syringe.

runs

Lancet, 1960, ii, 496.

" FOG FEVER " AND FARMER’S LUNG a great deal of interest your leading article.’ We too have had results similar to those outlined by Pepys and Jenkins.2 We have now analysed some 700 sera of farmers with pulmonary disease of undetermined aetiology. We have found that roughly 15 % of these patients have precipitins to Thermopolyspora polyspora, and that the rate of positive reactors among patients who have clinically and microscopically proven farmer’s lung is roughly 90%. But lacking from your article was our report3 of the isolation of T. polyspora from a patient with farmer’s lung. I believe that this paper further substantiates the work of Dr. Pepys and his declaration that the thermophylic actinomyces are closely linked with farmer’s lung. The organism was cultured from lung-biopsy material, and grew well on nutrient agar. Tubes were held at 60°C. An extract of this organism, the appearances of which were morphologically identical to T. polyspora, reacted with sera from this patient and from our other patients with farmer’s lung. This organism was later sent to Dr. Phillip Gregory’s laboratories, and he confirmed that this organism was indeed T. polyspora. Work in our laboratories is continuing in order to establish even more firmly the relations of the thermophylic actinomyces, and in particular T. polyspora, with farmer’s lung. FREDERICK J. WENZEL Marshfield Clinic Foundation, DEAN A. EMANUEL. Wisconsin. Marshfield,

SIR,-We read with

CELI. DESTRUCTION BY LYMPHOCYTES SIR,-In their article (Feb. 26) Tatiana Trayanova and her co-workers state that they have demonstrated " the role of immune lymphocytes in the pathogenesis of S.L.E. (systemic lupus erythematosus) ". We wish to comment on this. Destruction of cells in recipients by lymphocytes of homohas been postulated to occur in murine runt logous donors disease,45which may be regarded as a model system of autoimmune diseases. In human chronic lymphocytic leukaemia (C.L.L.), lymphocytes destroyed the patient’s own fibroblasts in tissue-culture; this reaction was unusually vigorous when Coombs-positive haemolytic anxmia was associated with leukaemia 6; thus, an autoimmune mechanism for cell destruction has been suggested. We have only limited experience with lymphocytes from patients with collagen diseases. In 2 patients with Sjogren’s syndrome, one with positive L.E. test, lymphocytic autoaggression in cultures of bone-marrow was minimal.8 1. 2. 3. 4.

5. 6. 7. 8.

Lancet, 1965, ii, 224. Pepys, J., Jenkins, P. A. Thorax, 1965, 20, 21. Wenzel, F. J., Emanuel, D. A., Lawton, B. R., Magnin, G. E. Ann. Allergy, 1964, 22, 533. Sinkovics, J. G., Howe, C. D. Tex. Rep. Biol. Med. 1964, 22, 591. Sinkovics, J. G., Shullenberger, C. C., Howe, C. D. ibid. 1965, 23, 94. Sinkovics, J. G. Nature, Lond. 1962, 196, 80. Sinkovics, J. G., Howe, C. D., Shullenberger, C. C. Blood, 1964, 24, 389. Sinkovics, J. G., Shullenberger, C. C., Howe, C. D. Unpublished.