738
JL precise record of haemorrhages not leading to deathwould admittedly have been a valuable contribution tothe question of the usefulness of vitamin K as a prophy-lactic, but the absence of such a record seems to me notto diminish the value of the mortality figures.Your second remark is that I have not investigated
the effect of obstetric factors such as instrumentallabour. Naturally, this is a factor of importance andI therefore wish to give some complementary data. Inthe following table different pbstetric factors duringthe control period and the vitamin period are registered.INCIDENCE OF OBSTETRIC FACTORS POSSIBLY CONTRIBUTING
TO THE FREQUENCY OF DEATH FROM HEMORRHAGE INTHE NEWBORN (PER 1000 BIRTHS)
* The maximumfrequency of high forceps in these groupswas 3%.
t Breech, transverse, brow and face presentations.
It will be seen that there is a certain increase instead ofa decrease in the frequency of instrumental factors(forceps) and of abnormal presentations in the vitaminperiod. No significant change is seen in the frequencyof the other obstetric factors investigated.
Thirdly, you discuss my inclusion of intracranial andsome visceral bleedings in the conception of " haemor-rhagic disease of the newborn " and seem to be of theopinion that I should have adopted the view of manypoediatricians-that traumatic and asphyxial bleedings<10 not belong to this disease. If I had done so, the mostinteresting result of my paper-namely, the remark-able reduction in deaths from intracerebral bleedingduring the vitamin period-would not have been ob-served. As pointed out above, this cannot be explainedby a lower incidence of obstetric factors in the vitaminperiod. A beneficial effect of vitamin K seems to me tobe the most probable explanation of this phenomenon.Further, the work of Rydberg (Acta path. microbiol.
scand. 1932, suppl. 10) indicates a high frequency ofinjury to the intracranial vessels in the newborn. Inview of the fact that up to 42% of all newborn babiesduring the first week of life for a shorter or longer timeshow a prothrombin index below 20 (= 5% prothrombin)and thus are disposed to bleeding from hypopro-thrombinaemia, it is not astonishing to find that prophy-lactic treatment with vitamin K led to a remarkablereduction in deaths just in the intracranial group ofbleedings. Salomonsen (Acta pcediat. 1939, 22, suppl. 1)stated that about 20% of all clinical cerebral haemor-rhages in the newborn are late and coincide with thephysiological hypoprothrombinaemia of the newborn.He therefore concludes (p. 74) that " morbus haemor-rhagicus must in these cases be held responsible for thedevelopment of the cerebral haemorrhage." Our greaterunderstanding of the mechanism of these bleedingspoints to hypoprothrombinaemia plus a lesion of thevessels, traumatic or inflammatory (Salomonsen pp. 9and 10). Concerning visceral bleedings, most of theseare perhaps of asphyxial origin. However, I see no
reason why a hypoprothrombinaemia should not be asdangerous a factor in asphyxial bleeding as in any otherbleeding. Therefore, your suggestion that the intra-cranial and most of the visceral bleedings should beexcluded from mv material seems to me not justified.
" Haemorrhagic disease of the newborn " has hithertoincluded many forms of bleedings with different aetio-logies (hypoprothrombinaemia, thrombopenia, fibrino-
genopenia, real ulcers, &c.). The determination ofprothrombin and the effect of vitamin K have made itpossible to distinguish the hypoprothrombinsemic group.Since this group seems to be responsible for the majorityof bleedings in the newborn, Salomonsen has character-ised his " morbus haemorrhagicus neonatorum " by thesubtitle" hypoprothronibinsemianeonatorum." As seenfrom my paper, I have followed his definition, and inconsequence all those groups of bleedings in which areduction in mortality was found after the administrationof vitamin K have been considered as belonging to thisdisease.
Gothenburg, Sweden. JORGBN LEHMANN.JÖRGEN LEHMANN.
VENOUS SPASM PREVENTING BLOODTRANSFUSION
SiR,-Dr. Humble and Dr. Belyavin in your issue ofOct. 21 indicate that the generalised peripheral venousspasm encountered during transfusion might be due to" a pathological central nervous reaction." A pathway
for conduction of constrictor impulses to the peripheralveins has been demonstrated by Donegan (J. Physiol.1921, 55, 226), who showed that stimulation of theabdominal sympathetics caused contraction of the veinsof the leg. His experiments extended previous observa-tions that peripheral stimulation of the sciatic nerveeffected contraction of the saphenous vein. Since thegeneralised spasm is consistent with the mechanism ofthe central vascular reflex, either a pathological reactionor a normal vasomotor response, it may be presumedthat efferent impulses are conducted by the demonstratedsympathetic pathway. If this conclusion is valid, itmay be possible to impede the constrictor impulses, in amanner similar to that used for relieving arterial spasm,by a sympathetic block. This would avoid the dangerswhich arise from a sudden cessation of the spasm whena transfusion is being given under pressure. -
Salisbury, Wilts. A. MACHALE HARMAN.A. MACHALE HARMAN.
TEMPORARY HOUSES AND THE FAMILY
IN his presidential address to the National Conferenceon Maternity and Child Welfare, held in London lastweek, Mr. Henry Willink, Minister of Health, said :" It has been suggested that a policy of building two-bedroomed bungalows is an attack on the birth-rate.The criticism is that since these bungalows are to havea life of ten years, then for ten years the families occu-pying them will be restricted to a two-bedroom size.With all respect I think this criticism is without founda-tion. The sole reason why the Government hasdecided upon a programme of temporary housing is thatit is calculated that by using labour and materials whichcannot be used for permanent housing, the number ofnew homes which can be built in the two vital andmost difficult years after the defeat of Germany will bedoubled. That is the sole reason for the temporaryscheme. These houses are intended for young couples,in order to provide as many as possible of them with aseparate home, as quickly as possible. Which offersbetter conditions for starting a family—a home of yourown, however small-or lodgings or a home withmother-in-law ? I have asked local authorities to makearrangements by which families which outgrow thebungalows may transfer to the permanent houses-ofgood standards and modern design--many of which willbe going up simultaneously. Other young couples willtake over the bungalows. May it not be that not one,but two or even three families may be started in abungalow during its ten years’ life ? "
LONDON SCHOOL OF HYGIENE AND TROPICAL MEDICINE.-Brigadier George Macdonald, MD, DPH, has been appointeddirector of the Ross Institute of Tropical Hygiene.
Dr. Macdonald, who was born in 19U3, is the son of the late J. S.Macdonald, FRS, emeritus professor of physiology in the Universityof Liverpool. He was educated at King Edward VII School,Sheffield, Liverpool Institute and the University of Liverpool, wherehe graduatedMB in 192J. He took .his DTM&H the same year andbecame a research assistant at Sierra Leone (1925-29). Afterward"he worked on "the research staff of the VIalaria Survey of India(1929-31), was medical officer to the Marian! Medical Association,Assam (1932-37) and the CEPA malaria control scheme, Ceylon(1938), and was appointed assistant director of the Ross Institute in1939. Dr. Macdonald will take up his new appointment on his releasefrom the Services.
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