Indian ,7. Pedlar., 26: 343, 1959.

ABSTRACTS OF THE CURRENT LITERATURE

THE NEWBORN

Hyperbilirublnaemia in prematurlty: GEORGE H, NEWNS and K. R. NORTON,--Lancet, 2 : 1 1 3 8 , 1958.

The death of four infants from kernicterus within the period of a few months in the author's hospital (one was below 2000 gm. at birth, three had gestation ages of 31-32 weeks and the fourth was born at thirty-five weeks; they died on the sixth, seventh, eighth and twelfth day respectively, and all showed widespread bile-staining of the brain-stem and thalamus on necrop- sy), led them to undertake an investigation on hyperbilirubinaemia in all subsequent infants who developed deep jaundice by measuring their serum bilirubin serially. Capillary blood was used. As the 'direct ' bilirubin level was found to be very low (less than 1 mg.) in the few cases, where serum bilirubin was measured, it was not done routinely. Rh incompatibility was excluded in all and ABO in most cases.

The authors' series comprised fifty-two "premature" and sixteen "full t e rm" infants as judged by their weights. Only five of the latter were born at full term, others being of 35 to 38 weeks' gestation. In the premature group, the maximal serum bilirubin level ranged from 9 to 43 mg. per cent. In twenty-four, it was 20 mg. per cent or more, in fifteen cases 25 mg. per cent or more; eight had exchange transfusions. In only three of these fifteen cases there were signs of kernicterus. None died. In the so called full term group, the level ranged from 15 to 35 rag. per cent. Ten of these had 20 mg. per cent or more; four of these were born at term.

The bilirubin level was highest on the fourth day in 44 per cent, on the fifth day in 19 per cent and on the sixth day in 15 per cent of cases. The authors could not show any significant correlation in this series between the birth weight or gestational age and maximal bilirubin levels.

Exchange transfusions were given in eight of the premature and in one of the full term group. In four, the level had reached above 20 mg. per cent and in four, above 30 mg. per cent; twenty-five infants with levels 20 mg. per cent or more were not given transfusions as they appeared clinically normal. None of these developed kernicterus. The amount transfused was 160 ml. per kg. body weight. These eases were followed up for a few months to two years without finding any sequelae.

I t is significant to note that all the four cases, who died of kernicterus, received 30 mg. of 'synkavit ' in the first three days of life. O f this series, thirty-three had only 1 mg., and only four received more than 10 mg.

The authors performed an exchange transfusion when the serum bilirubin exceeded 30 mg. per cent or if indicated clinically. They suggested that hyperbilirubinaemia increased the risk of development of

344 Indian Journal of Pediatrics

kernieterus when levels exceeded 30 mg. per cent, and the risk was very low if levels were below 10 to 20 rag. per cent.

M.S. RAO.

T h e c a u s e s o f tears o f the t e n t o r i u m in the n e w b o r n : M. SCHMIDT- MANN.--Dtsch. Med. Wschr., 83; 1783, 1958. From Int. Med Dig., 74: 120, 1959.

Mechanical factors always do not explain tears of the tentorium in the newborn. Tentorial tears may be found in prematures who have been delivered rapidly and even in caesarian section babies, whereas in difficult deliveries ofpostmature babies, a large caput succedaneum may be encountered without any tear of the tentorium.

The author has shown that meningoencephalitis was demonstrated in all newborns following tears of the tentorium with intracranial hemorrhage, and in the majority of these cases, toxoplasmosis had to be assumed as the cause. Though the number of cases were small, the findings were identical, viz. tentorial tears, meningoencephalitis, hemorrhage, calcified ganglion cells, positive Sabin-Feldman test of the mother and occasionally demons- tration of the toxoplasma itself.

The author concludes that mechanical factors are of lesser significance for the occurrence of a tear of the tentorium. A normal tentorium does not tear even on intense mechanical stress; only one with inflammatory affection tears. Therefore, in such cases the cause should be investigated and the mother treated.

M. AMRUTHAVALLI.

I N T E R N A L MEDICINE

Sys to l i c m u r m u r s in chi ldren: W. MAINZER, R, PINCORICI and G. HEYMANN---Arch. Dis. Childh., 34: 131, 1959.

The authors examined 2,035 children up to the age of 15 years, of which systolic murmurs were present in 240 cases.

The children were divided into three age groups: from one month to five years; from 5 to 10 years and; from 10 to 15 years. The incidence was highest in the age group 5 to 10 years, and more male children were found to have systolic murmurs (fifty-six per cent) than females (forty-four per cent). Murmurs were classified into four types: innocent murmurs; murmurs due to possible heart diseases; murmurs due to pr6bablehear t diseases; and mur- murs due to organic heart diseases. Out of 240 systolic murmurs, 64.2 per cent were innocent and 35.5 per cent were considered to be pathological, which could be proved by fluoroscopic and electrocardiographic examina- tions and other laboratory tests. No physical criterion could be found to dis- tinguish an innocent murmur , either in realation to intensity, location or continuity of the murmur~ The authors observed that a high percentage of systolic murmurs were present among siblings. The highest proportion of

Abstracts of the Current Literature 345

systolic murmurs were found among the so-called mediterranean group followed by the children of western origin, whilst the lowest percentage was discovered among the children from India.

S.K. MUKHERJEE,

A n a p h y l a c t o i d react ion to ora l penic i l l in . R e p o r t o f a case: FRANK J. MARTIn--Ann. Int. Med., 4 9 : 6 6 2 1958. From Int. Med. Dig., 74: 88, 1959.

The case illustrates a severe anaphylactoid reaction to an oral peni- cillin G tablet (50,000 units).

Within thirty seconds the patient had a feeling of suffocation in the neck and upper part of the chest and collapsed. Physical examination revealed a cyanotic, acutely and critically ill elderly female patient. On auscultation, wheezes in the chest were heard; B.P. was not obtainable. Heart sounds were indistinct. E.C.G. showed S waves in leads 2 and 3, dep- ressed SST in AVF and also in V 4, 5 and 6. Hb was 17.3 per cent. E.C.G., B.P. and Hb. became normal after twenty-four hours. History indicated that she had many injections of crystalline penicillin in the past. She had liver extract and injections of penicillin in 1949 after which she developed urticarial rashes which was attributed to the liver extract injections.

The above case shows that penicillin anaphylaxis, both orally and par- enterally, should be considered in every patient seen in shock.

The treatment of such a condition depends greatly upon the use of ad- renalin, noradrenalin, hydrocortisone and penicillinase.

The problem of penicillin sensitivity has become very important. It is weU known that patients who have previously shown allergic manifestations and those with atopic dermatitis and asthma are prone to develop the more serious reactions.

Since drugs do not prevent penicillin reaction and sensitivity tests are not predictable, it seems that the best preventive is its use only when absolu- tely indicated.

M. AMRUTHAVALLI.

Infant i l e s p a s m s and h y p s a r r h y t h m i a : B. D. BOWER and P. M. JEAVONS --Lancet, 1 : 605, 1959.

Although there has recently been revival of interest in infantile spasms, understanding of this variety of epilepsy is hardly greater today than it was a hundred years ago. The clinical features of twenty-two patients with infan- tile spasms are described. There were fifteen patients with flexor spasms and seven with extensor spasms as the presenting feature. This rare form of epilep- sy usually starts at about the sixth month of life. The spasms are general- ised, rapid and brief. It may be followed by a cry, and is often repeated to form a series. Definite mental retardation is almost invariably associated with it. In about half the cases there is a "history of prenatal or perinatal cerebral demage", and in these cases mental development is usually retarded from birth. Physical abnormalities may be found in this group. In the other

6

346 Indian Journal of Pediatrics

half, the aetiology is unknown, and in these children mental development is usually normal up to the time of the first spasm.

Anticonvulsants do not usually inhibit infantile spasms but chlorte- tracycline may temporarily do so. Corticotrophin and cortisone have been used recently and the initial results are promising. All workers agree that most patients ramain mentally defective, although the spasms diminish in frequency or disappear. A few die within a few years of the onset of spasms.

In patients with infantile spasms, the E.E.G. is almost always abnormal but definite hypsarrhythmia is found in only half the records (sixteen out of thirty-two); others show an epileptic abnormality which is often severe. By contrast, more than half the patients with epilepsy (not infantile spasms) in the same age group have a normal E.E.G. and hypsarrhythmic record is rare. Although a non-hypsarrhythmic, epileptic record may be found in patients with infantile spasms, E.E.G. examination of suspected cases is very useful; for a normal record is strongly against the diagnosis, while a hypsa- rrhythmic one is very much in favour of it.

R.P. MISRA.

Dietary treatment o f an infant wi th phenylketonurta: F.S.W. BRIM- BLEGOMBE, MARGARET E. R. STONEMAN and R. MALIPHANT--Lance/, 1: 609, 1959.

Very rarely in an untreated case, the infant retains normal or near normal intelligence. Drastic restriction of dietary phenylalanine can reduce the abnormally high blood-level of this aminoacid to normal; but the effect of such treatment on the intelligence of these patients varies greatly with the age at which treatment is started. Sooner the treatment starts, better the result. The authors recorded the progress of an infant in whom minor inte- llectual deterioration had apparently started (at seventeen years of age) when treatment was initiated and in whom there was a highly suggestive evidence of recovery and maintenance of normal intelligence over a two- year period of treatment. The child had been treated on a diet in which both phenylalanine and tryptophan were restricted to approximately 25 mg. per kg. body weight daily. However, this level of restriction was found to be insufficient in some cases to reduce the blood level of phenylalanine to normal. Hence in each individual case, dietary restriction of phenylala- nine should be so regulated as to maintain the blood level of phenylalanine within normal limits.

The associated restriction of dietary tryptophan to approximately 25 rag. per kg. had not interfered, in two and a half years, with the child's weight gain and general nutrition.

Studies of affected siblings of known cases indicate that the blood level of phenylalanine may begin to rise between the second and the sixth week of life, and dietary restriction should be started as soon as possible. All infants should have their urine tested for phenylketones at the age of 3 weeks and possibly again at 6 weeks,

R. P. MISRA,

Abstracts of the Current Literature 347

Investigations into the aetiology and treatment of pica: PHILIP LANZKOWSKY--Arch. Dis. Childh. 34: 140, 1959.

Twelve children, who attended the Red Cross Hospital Out-patient Depar tment with pica, were investigated. Most of them used to take sand, black coal, pieces of wood, black soil and clay. The appearance and physique of the children were not conspicuously abnormal. Five of the children showed clinical evidence of anaemia, one showed clinical signs of undernutrition and one of them was diagnosed to be suffering from lymphosarcoma. Ten children (83 per cent) gave a history ofascaris infestation, one child had tape- worm and another trichuris trichura. The intelligence of the children as a whole in this survey was average. Radiological examinations were done in eight cases and five of them showed opaque material, interpreted as sand or stones, in the large bowel and to a lesser extent in the small bowel. On investigation, blood haemoglobin level ranged from 3.0 gm. per cent to 10.9 gm. per cent with a mean of 7.89 gm. per cent. Serum protein estimations were done in eleven cases and the results showed a mean of 7.19 gm. per- cent for total protein, 3.87 gm. per cent for serum albumin and 3.32 gin. per cent for serum globulin. After the investigations, intramuscular iron- dextran compound (imferon), in doses varying from 200 to 400 mgm., was given in nine cases. All the children showed a complete cure of their pica, within one to two weeks of the commencement of treatment, with a rise of the blood haemoglobin level. None of these patients were given any anthel- mintic treatment during this period. The author concludes that iron defici- ency is the major cause of pica and that iron theraphy is curative.

S. K. MUKHERJE~.

Defective lactose absorption causing malnutrition in infancy: A. HOLZEL, V. SCHWARZ and K. W. SUTCLIFFE--Lancet, Vol. 1, March 30, 1959, pp. 1126-1128.

The authors report case histories of two siblings who were failing to gain in weight in spite of adequate food intake and were having increased number of stools, flatulence and colic. After thorough investigation~ it was found that this failure to thrive was due to a selective inability to metabolise lactose. This was confirmed by lactose a rd glucose-plus-galactose absorption tests. Moreover, the patients gained in weight by addition of non-lactose carbo- hydrate to the diet. The authors describe this condition as a hitherto un- recognized congenital abnormali ty and suggest that as this enzyme defect is present in two siblings the condition is hereditary. In breast-fed infants the manifestation of the condition is likely to be more than in babies who take dried milk preparation containing sucrose or glucose.

U. SARKAR.

Acut encephalitis in childhood: LUDO VAN BOOAEgT--Brit. med. J . , May 9, 1199, 1959.

Encephalitis in childhood was discussed by the author, who also strived to correlate the clinical picture with histo-pathological findings. This was

348 Indian Journal of Pediatrics

done with a view to obviate the necessity of an early and correct diagnosis of the condition, as welt as etiological factors, to be able to judge the suitable treatment and modify the prognosis, if possible.

The need for differentiating actual encephalitis, where an infective agent acted locally on the brain tissue, from conditions where such an agent lay externally but exerted a toxic action on it, as in some infectious diseases, was emphasised; also, clinically when the meninges were involved along with the brain, as is frequent. Almost all the above, according to the author, caused cerebral venous circulatory changes which interfered with meta- bolic activity causing intoxication.

The diagnosis and significance of meningoencephalitis, the positive signs of viral diseases, allergic reactions (stimulating or causing actual encephalitis), acute haemorrhagic encephalitis, the diagnosis and differen- tiation of the entities 'eneephalopathy' and 'encephalitis', cerebral herpes, acute necrotizing encephalitis, 'leucoencephalitis', late encephalitides and and the treatment of acute eneephalitides of childhood were considered separately and in some detail.

Viruses were considered to be the main etiological factor causing true encephalitis. Not only were they closely similar in their clinical and patho- logical manifestations, but also were very difficult to establish separately in a laboratory and especially when absent in blood, unless the laboratory was especially equipped for virological studies.

Treatment of the primary disease, use of anticoagulants (in thrombotic lesions) and other palliative measures, use of salicylates and idodides and the treatment of shock were mentioned. Cortisone was apparently not found much useful by the author.

M. S. RAO.

S U R G E R Y

T h e v e n o u s c u f d o w n : EDWARD G. STANLEY-BRowN--Arch. pediat., 75: 480, 1958

Considering the great importance of performing a "venous cutdown" in pediatric surgical practice and to minimise their technical difficulties and complications, the author considered it worthwhile to present a tech- nique which, although not new, had proved satisfactory.

The number of accessible veins being restricted in a newborn, empha- sis was laid on a correct procedure, whereby conditions like the so-called "congenital absence of saphenous vein" were ruled out, and also that if kept unligated the same vein could be utilised again, when the incision in the vein-wall was healed and the lumen reeanalised after an interval of ten days to three weeks.

After reducing the possibly unnecessary instruments in a cutdown set, the author found some nineteen items useful. In addition to a description of the main instruments, the technique and procedure of performing the

Abstracts of the Current Literature 349

"cutdown" was described stage by stage with the following important points, such as details regarding the plastic catheter (canula), sterilisation of instruments, handiness of a transfusion set fully prepared in advance, immobilisation of the limb, lighting, anaesthesia, the incision, control of bleed- ing, dissection, threading and incising the vein, cannulation , skin suturing and all the necessary precautions during the whole procedure, etc.

M. S. RAO.

NUTRITION AND BIOCHEMISTRY

Electrophoretic differential s erum protein pattern in Kala-azar: AJAI SHANKAR--Brit. med. J., May 9, 1221, 1959.

Prompted by the fact that the British Medical Jonrnal (1957) had failed to mention kala-azar while discussing hyperglobulinaemia, the author reviewed a previous article, of which he was a co-author, and compared it with others on the same subject; these, he claimed, were only six in num- ber published hitherto.

The main features of the electrophoretic differentiation of serum proteins in the nineteen patients suffering from confirmed kala-azar ("lar- gest number published so far") and their comparison with other published and unpublished data revealed that (1) the total serum proteins were slightly raised (with an average 7.58 gm. per cent) with a marked fall in the serum albumin (average 45.4 per cent) and no significant change in the other fractions, (2) neither any abnormal (slow) motility of the globulins, nor any "fraction X" in the serum proteins, as claimed by some workers, was found in the reviewed series.

Aldehyde positive cases showed a higher degree of hyperglobulinaemia. The author stressed the need of including kala-azar in the list of other conditions such as multiple myeloma, sarcoidoses and collagen diseases, which cause marked hyperglobulinaemia, especially when the globulins are raised above 5 gin. per cent. Unfortunately, the ages of the patients were not mentioned in the reviewed series.

M. S. RAO.

Observat ions on haemoglobin A2 component in paper electropho- resis: J.B. CHATTERJEA, SUSHIELA SWARUP and S. K. GHOSH--BuII. Calcutta Sch. trop. Med., 7: 6, 1959.

Recent literatures show that normal adult haemoglobin consists of four components--Aj, A2, Aa, and A4. Various components of haemoglobin A originally described on starch block are, according to the authors, also identifiable on paper electrophoretograms when the paper employed is relatively thick and the haemoglobin solution used is relatively large. The different components are better visualised after staining. In the present communication the authors have presented their observations onA2 compo- nent in thalassaemia as studied by paper electrophoresis.

350 Indian Journal of Pediatrics

Samples from twenty normal, sixty-three heterozygous thalassaemia, sixteen homozygous thalassaemia and seventy heterozygous haemoglobin E subjects were studied. Compared to normal controls, A 2 (when expressed as a percentage of total haemoglobin including haemoglobin F) was significantly increased in thalassaemia heterozygote. In homozygous thalassaemia, A 2 was, in many instances, elevated though not to the same degree as in heterozygous thalassaemia. A2, when expressed as a percentage of haemoglobin A (excluding haemoglobin F), showed definitely elevated values in homozygous thalassaemia. According to the authors, in homo- zygous thalassaemia suppression of haemoglobin A is mostly due to the suppression of haemoglobin A1, with the result that the ratio At/A2 is lower than that of thalassaemia trait. The relative increase of A 2 may thus be an expression of thalassaemia gene.

U. SARKAR.

A method for determination of haemoglobin in plasma by near- ultraviolet spectrophotometry: M. HARBOE, Stand. J. di~. Lab. Inoest., 11: 66, 1959.

In this paper the author describes a method for the determination of small amounts of haemoglobin by spectro-photometer. Here the.determina- tion is done by means of the Soret band which is more sensitive and more accurate, as this band is far more intense than the visible absorption bands. The experiment shows that there is marked difference in the Soret band of oxyhaemoglobin and carboxyhaemoglobin. This difference is used to identify the absorption due to oxyhaemoglobin. In this simple method, the oxyhaemoglobin is identified by the change in light absorption after conversion to carboxyhaemoglobin. The absorption due to turbidity and normal plasma or serum perse may be eliminated by the application of Rimin- gton and Sveinsson's formula. The difference between the Soret bands of oxyhaemoglobin and reduced haemoglobin does not interfere with the determination, because under the experimental conditions all haemoglobin is converted to oxyhaemoglobin. The conversion of even small amounts of oxyhaemoglobin to alkaline haematin interferes by giving too low values for the pigment concentration. The author has discussed its elimination.

U. SARKAR.