Reginald Lightwood

Biliary Obstruction Associated with Icterus Gravis Neonatorum

For twenty years it has been known that obstructive jaundice may occasionally be seen in icterus gravis neonatorum. Still (1927) quoted the view that the bile of excessive haemolysis becomes too viscid to pass freely along the ducts, and he mentions the low pressure at which it is secreted. This view does not altogether explain the facts, because a marked obstructive phase does not necessarily go with the greatest haemolysis or the deepest preceding jaundice. MacClure (1931) suggested that the presence of a foreign substance in the bile caused coagulation in the bile capillaries. We favour a third possibility-namely, that biliary obstruction is due to swelling of damaged hepatic cells-because histological studies of icterus gravis show that such an association exists. The association is seen also in conditions other than icterus gavis, for example, stagnation of bile may be seen just outside areas of maximal necrosis in infective hepatitis. Skelton and Tovey (1945) postulate two forms of biliary obstrution in association with icterus gravis: (a) blockag of one of the larger bile ducts with inspissated bile; and (b) conversion of the bile ducts into a fibrous cord. First let us consider the latter, that is, atresia ofthe bile ducts associated with icterus gravi

Cross-infection in Children's Wards: Report to the British Paediatric Association.

The term cross-infection is here used to denote any infection acquired by a patient in the hospital environment. Clinically, it is an infection arising during the course of another illness for which the patient was originally admitted to hospital, and may attack the respiratory tract, gastro-intestinal tract, wound, skin, or mucous membrane, or be manifested as one of the specific fevers. Cross-infection is a constant anxiety to all concerned with the hospital care of sick children and infants, the latter particularly calling for special protective measures. A great deal has yet to be learned. No explanation, for example, has been given for one of its outstanding features-namely, its fortuitous onset. It is well known that, in spite of overcrowding and poor hygiene, one ward may for long be without manifest crossinfection, whereas another which has every facility and is staffed by well-trained nurses may suddenly be the site of a virulent outbreak. In spite of this it would be folly to ignore the value of adequate preventive mreasures. Cross-infection which results in nothing more than a mild catarrhal illness, at times apyrexial, must not be dismissed lightly. There is evidence that this may be but the prelude to outbreaks of increasing severity culminating in a series of fatal illnesses. The virulence of the infection may apparently be increased by passage, and unless prompt measures are taken to control the initial outbreak there may be a calamity. Pemphigus neonatorum furnishes an example of this feature. An outbreak may begin with one infant having a single lesion no more than a few millimetres in diameter. Failure immediately to apply protective measures may be followed by the development of pemphigus in successive patients in whom the illness is progressivelv more severe, ending in a generalized toxaemia. Cross-infection by infectious fevers, measles, or chicken-pox, for example, seriously hinders the work of a childrens department, for such outbreaks necessitate the closure of a ward or wards for an indefinite period. Whilst a good deal has been written about cross-infection in childrens wards, the frequency, extent, and results of this have never been ascertained. In order to provide this information a special ad hoc committee was invited by the British Paediatric Association to present its views on the problem, and the Association has instituted an inquiry to collect evidence on the incidence of cross-infection. The obtaining of this evidence will take time, but the results of the inquiry will be published in due course. The report of the Committee which is here presented is a broad statement of our present knowledge on cross-infection, and, although suggestions are made as to how it may be controlled, opinion is still divided on so many points of detail that the report is more in the nature of a preliminary discussion intended to bring before the profession generally, and those in charge of childrens wards in particular, the many problems that have to be faced in the control of cross-infection. This procedure of issuing a report before the exact nature of the problem has been defined may justly be criticized, but it has been done deliberately in this way, in the belief that such a report may help hospital authorities about to create or to improve their facilities for the care of sick children.