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excluded from the hospital services. To say the least,it is indefensible to keep highly skilled men from working,and at the same time to complain about the long waiting-lists for admission and delays in outpatient appoint-ments; it should surely be possible to increase thenumber of outpatient sessions. Quousque tandem? z

SPECIALIST.

FORTITUDE OF A FŒTUS

SiR,-In some women surprisingly little trauma isneeded to precipitate an abortion. Operations on theabdominal organs have a bad reputation in this respect,and operation for appendicitis is followed by abortion orpremature labour in 40-80% of cases.! In the followingcase two operations were done for acute abdominalconditions during pregnancy in a woman with a badobstetric history. Though at one time abortionthreatened, the patient was eventually delivered ofa live baby.Mrs. X, aged 29, was first seen on Nov. 16, 1947, when she

was admitted to the Liverpool Royal Infirmary with anappendix abscess. The only previous illness which sheadmitted was trinit.rotoluene poisoning in 1942. Her obstetrichistory was that in 1939 she had- given birth at term to ababy which was stillborn and macerated for no known reason,and in 1946 she had been delivered of a stillborn baby atterm after having had pre-eclampsia during that pregnancy.The appendix abscess was treated conservatively, and afterten days in hospital the patient was discharged with theadvice to return in three months for anappepdicectomy.,

When the patient did return on April 7, 1948, she was abouttwelve weeks’ pregnant, her last menstrual period havingstarted on Jan. 6, 1948. There were no symptoms or signsof appendix trouble. In view of the unfortunate obstetric

.history it was decided, after discussion, to postpone appendi-cectomy until after delivery. However, six weeks later thepatient was readmitted, with recurrence of her appendixabscess, and was again treated conservatively. At that timedirect radiography of the abdomen revealed numerous bismuthinjection tracks in the buttocks, and further questioningelicited the fact that the patient had received an incompletecourse of treatment for secondary syphilis in 1945.On this occasion there was no response to conservative

measures, and therefore on June I a large retrocaecal appendixabscess was drained, under general anaesthesia, by Mr. MauriceSilverstone. At operation there was some soiling of the

peritoneal cavity. The postoperative course was ’stormy.The day after operation the patient threatened to abort,and shortly afterwards she developed paralytic ileus. These

complications were treated with morphine, gastric aspiration,and intravenous fluids. Progesterone was not given. Afterfour days peristalsis re-started and the patient’s generalcondition steadily improved. The following week faetalmovements were felt for the first time. Sulphonamides andpenicillin (16,400,000 units in 24 days) were given in the post-operative period. The discharge from the abscess ceased afterfour weeks, and the patient was transferred to a convalescenthome. The pregnancy was then progressing normally. Theblood Wassermann reaction was negative, but it was intendedto refer the patient to a venereologist on her return from theconvalescent home.On July 18, however, she was readmitted, as an emergency

case with acute obstruction of small bowel. The uterus

corresponded in size to a 26-week pregnancy, and foetal move-ments were felt. It was thought that the cause of the obstruc-tion was a kink in the terminal ileum, which had been producedby the enlarging uterus and adhesions in the right iliac fossa.In view of the possibility that re-exploration of the appendixarea might light up a latent infection or precipitate abortionby disturbing the uterus it was decided to do a short-circuitingoperation. Accordingly on July 20 a side-to-side anastomosisbetween the terminal ileum and the transverse colon was doneunder general anaesthesia, by Mr. Silverstone. Except fordiarrhoea, which persisted for a week, the postoperative coursewas uneventful, and the patient was discharged from hospitalon Aug. 1. ’

Meanwhile the pregnancy proceeded uneventfully, exceptfor mild hydramnios. On the advice of the venereologist,1. Baer, J. L., Reis, R. A., Arens, B. A. J. Amer, med. Ass. 1932,

98, 1359.

Dr. A. O. F. Ross, the patient was given penicillin 4,200,000units in ten days. This was to be followed by Stabilarsan ’0-45 g.-weekly until the end of the pregnancy, but only twoinjections of arsenic were in fact given.She was admitted to the maternity ward on Oct. 1 in

premature labour. She was very apprehensive-not unnatur-ally, in view of her previous obstetric history-and herapprehension was reflected in,the incoordinate uterine actionwhich marked her labour. The baby was eventually extractedwith forceps, face to pubes, under local anaesthesia, theindications being secondary uterine inertia and small but

persistent intrapartum hoemorrhage. At the end of the secondstage intravenous ergometrine 0-5 mg. was given, and theplacenta was delivered with the next contraction. However,a true atonic postpartum haemorrhage followed, and a pintof matched blood was transfused. The intrapartum haemor-rhage, together with the postpartum loss, were most probablydue to a lateral placenta proevia, but it was impossible to provethis.The baby, a male, weighed 5 lb. 2 oz. and was judged to be

of 38 weeks’ maturity. He liad asphyxia pallida at birth butresponded to treatment, and when seen three months laterhad made satisfactory progress. ’

To summarise, this woman became pregnant after

having had syphilis (incompletely treated), pre-eclampsia,and two stillbirths. After drainage of an appendix abscess -sshe developed paralytic ileus and threatened to abott,and finally she underwent an operation for the relief ofacute small-bowel obstruction, all within a span of 8weeks. The child survived, during labour, an intra-partum haemorrhage and secondary uterine inertia and,immediately after birth, asphyxia pallida.We wish to thank Prof. C. A. Wells, Mr. M. Silverstone,

and Prof. T. N. A. Jeffcoate, under whose care the patientwas, for permission to publish this case.

Liverpool Royal Infirmary.

S. BENDERClinical Assistant.

R. B. WELBOURNSurgical Registrar.

CONCENTRATION OF DIPHTHERIA ANTITOXININ CORD BLOOD

SI[R.-I cannot let Dr. Wiener’s latest letter, whichappeared last week, pass without comment. "

I am glad that he has withdrawn his suggestion thatthe differences in antitoxic titre recorded between cordand maternal blood are too small to be significant ; buthe now suggests that the results might be affected bybias in the setting up of the experiment. A little coD-sideration of the details given in my last letter shouldhave shown him that this was highly improbable. Wealso have long series of thousands of records which showthat the variation from guineapig to guineapig is not

significantly greater than the variation between identicaltests on the same guineapig. It is abundantly clear thatDr. Wiener is basing his criticism on his own experienceof the much less accurate type of serological test withwhich he is familiar.

’

As regards our titrations, in the first place the cordand maternal samples were received at the same timeand were therefore tested in parallel on one day usingone animal, and the tests were repeated likewise. How-ever, since there is no significant animal variation andthe test toxin is always controlled by means of two stan-dard sera, this particular " precaution " would be quiteunnecessary. Nevertheless I accept Dr. Wiener’s chal-lenge by making available to him the protocols of thelast set of tests made on mother’s and cord blood samples :D t S t au" -

Antitoxin (units per ml.) ,

Date, Sept. Guineapig Mother’s blood Cord blood -

23 .. Same .. 18-22 .. 3624 .. Another .. 18-22 .. 36-452 .. Another- .. 20-22 .. >4028 .. Another...... 40 ; <45

An earlier sample of the mother’s blood, taken sevendays before delivery, had the same value as this samplewhich was taken during labour. On the same four days

716

tests on the two standard sera tested at 10% differencesgave the following results : (a) 95, 95, 95, 88 units perml. ; (b) 2-07, 1-90, 2-10, 1-93 units per ml.Thus we found in this series of three tests that the

mother’s serum failed each time to pass tests for 22units but was over 18 or 20 units, whereas the serumfrom the cord blood was over 36 units on each of the fouroccasions it was tested. The values allotted were 21 and41 units respectively, and the high titres were due to thefact that the mother had been immunised earlier in

pregnancy. &deg;

In conclusion I would suggest a better idea than Dr.Wiener’s as to the relation between theory and observa-tion : when an observation of undoubted accuracyconflicts with " an excellent theory," it is also a goodthing to re-examine the theory. As yet we have no theoryto account for the phenomenon, but we are continuingthe investigation&mdash;giving due consideration to anypoints on the practical side which might throw light onthe matter.Wellcome Research Laboratories,

Beckenham, Kent.MOLLIE BARR.

VASCULAR STASIS

SIR,-I read with great interest last week’s letter onvascular stasis by Professor Kreyberg, of Oslo, and yourannotation ; and I should like to support the plea forfurther study of this phenomenon.At this unit an investigation of experimental and

clinical burns is in progress, and we have found evidencethat the inflammatory reaction plays an important partin influencing the course of burns. ’

During a recent study 1 of experimental burns ofknown temperature applied for known periods in guinea-pigs, the permeability and qualitative blood-flow changesin the skin were investigated by the use of circulatingEvans blue and/or brilliant vital-red injected before andafter burning. It was shown : (1) that continuation ofthe dermal blood-flow in burned skin was accompaniedby -normal skin sensation, by the absence of markedoedema, and by the absence of subsequent whole-skinloss ; (2) that the development of stasis of the localblood-flow in the dermis was preceded by marked oedema,was associated with analgesia, and was followed bywhole-skin loss.

’

Further,- evidence has been provided of the existenceof a threshold dermal temperature, below which stasisdoes not occur. If, however, the dermis is heated to orbeyond this temperature during burning, stasis of thedermal vessels develops. The time of onset of stasisdecreases with increasing severity of burning. Stasis is

preceded by a period during which slowing of the blood-flow progresses to extreme retardation or stagnation(prestasis of Kreyberg). During this period the vesselsare freely permeable and oedema develops.In our experience, stasis throughout the depth of thedermis in guineapig burns is invariably followed bywhole-skin loss, and this would suggest that the changeis normally irreversible. However, in a number of burnsin which stagnation of the blood-flow was detected,partial, and not whole-skin, loss took place. This

suggests that stagnation was not followed by stasis, orthat if stasis did develop it was localised to the superficialpart of the dermis.

Investigations are in progress with the aim of -dis-

covering how to influence these vascular changes. Variousanti-histamine drugs have failed to influence the

capillary-permeability and blood-flow changes in experi-mental guineapig burns of all degrees.2

In my opinion-and no doubt Dr. Kreyberg will

agree-stagnation and stasis, when they occur, are partof an inflammatory reaction, and any investigation into

1. Sevitt, S. J. Path. Bact. (in the press).2. Sevitt, S. Brit. J. exp. Path. (in the press).

their nature and cause must take the whole processinto account.

Finally, I should like to comment on Professor

Kreyberg’s choice of the word " prestasis " for extreme

retardation of the blood-flow. This word implies thatthe condition invariably ends in stasis, althoughProfessor Kreyberg agrees that this is not necessarilytrue. In my opinion the word " stagnation " is freefrom this criticism and is therefore to be preferred.

M.R.C. Burns Research Unit,Birmingham Accident Hospital. S. SEVITT.

AN EPIDEMIC OF ACUTE NEPHRITIS

SIR,-I read with great interest Dr. Fleming’s articlein your issue of May 7.As physician in charge of the outpatient clinic of the

Transjordanian Red Crescent Society in Amman, I facedthe same problem of an epidemic of acute nephritis amonginfants- of the Palestine Arab refugees.

In my private clinic in Amman, I have during the lastthirty months seen only three cases of acute nephritis.But in the seven months between October, 1948, andApril, 1949, I saw more than one hundred cases of acutenephritis among the refugee children. This prevalencewas due perhaps to the bad conditions under which therefugees were living (most of them were in tents or caves}and to the extremely cold and damp weather.

I did not have the advantage of a well-equippedlaboratory, nor enough beds in the hospital, to investigatethese cases fully, but the following features were noted :(1) most of the cases were in females ; (2) their age wasusually under 3 years ; and (3) commonly they had hada course of sulphadiazine in the preceding two weeks forinflammation of nasopharynx, otitis media, pneumonia,or diarrhoea. The diagnosis of acute nephritis was

based on the presence of oedema and albuminuria with orwithout fever.

In the early cases of this series treatment consisted atthe start in routine dietetic and diuretic measures, whichhad very little effect. When, after fifteen days, the condi-tion was not greatly improved, I injected 200,000 unitsof penicillin once daily for three successive days. The

improvement was so striking that I treated subsequentcases with penicillin as soon as the diagnosis was made ; ;.in the majority cure was complete within one week.

This experience contrasts with that of Dr. Fleming.But I believe that had he used greater amounts of peni-cillin, or subdivided the dose into smaller amounts givenat shorter intervals, his results would have been different.

Amman, Transjordan. M. RAZZAZ.

PURIFIED TOXINS FROM COBRA AND BEE

SIR,&mdash;I have developed a technique for preparing inpotent amorphous and crystalline form the venom fromthe cobra (Naja tripudians).The cobra is allowed to bite a rubber membrane covering

a small beaker. The venom thus collected, which consists,of about 1 ml. of viscid, clear, transparent liquid, is diluted100 times with physiological saline solution. It is clarifiedby adding a little aluminium sulphate and lime water;.and toxin is then precipitated by the addition of pure acetone.The precipitate is centrifuged, washed with acetone and thenwith ether, and finally dried in vacuo, leaving the toxin as awhite -amorphous substance. Alternatively the precipitatemay be concentrated by evaporation under reduced pressureat 30&deg;C and the toxin crystallised by drying in vacuo overphosphorus pentoxide. One bite produces 104 mg. of thefinal crystalline toxin.

This crystalline material is strongly active when

injected subcutaneously into rats ; 0-03 mg. is sufficientto kill an albino rat of 100 g. body-weight.A second method of preparation is as follows :The venom, which is collected as in the first method, is

diluted 100- times with N/10 hydrochloric acid and is thenneutralised with normal caustic soda ; a saturated aqueous