ELDERLY PSYCHIATRIC PATIENTS MEDITfISH 679reactions, or long-standing personality disorders, or dementing illnesses is possible. It is useful in allowing us to concentrate our limited facilities for active treatment on the patients most likely to benefit. But classifying our patients with a view to "disposal" does not mean that we subscribe to a watertight system of disease entities, or assume that affective illness precludes insidious organic dementia. The fact that active treatment was advised in 17 patients belonging to groups thought to be therapeutically unrewarding indicates that we have not been using our three types rigidly, but merely as points of orientation. To an increasing extent we are attempting to treat elderly patients as outpatients whenever possible. Apart from the obvious advantages, this furnishes us in doubtful cases with a period of observation during which to assess the relative importance in the individual patient of irreversible dementia, lifelong or long-standing personality disorder, or of affective, and thus mostly reversible, reaction. Her first pregnancy, in 1939, ended in a stillbirth at 28 weeks gestation; her second pregnancy, in 1941, ended in an abortion at 24 weeks; her third pregnancy, in 1943, ended in a stillbirth at 38 weeks gestation (at this time she had a blood transfusion, but the full details are not available, and, of course, this was before the days of routine rhesus grouping); her fourth pregnancy, in 1945, ended in a stillbirth (spina bifida) at 36 weeks; and her fifth pregnancy, in 1950, ended in a stillbirth at 36 weeks; there was an associated mild toxaemia, and antirhesus antibodies were found early in this pregnancy. Her last menstrual period was April 3, 1951. She was blood group A Rh-negative (cde/cde), and blocking antirhesus antibodies were present in the serum. The husband belonged to blood group 0 Rh-positive; the most likely genotype being CDe/cDE.
SummaryThe pregnancy continued normally, and serological examination showed virtually no change in the antibody litre. At the thirty-third week of pregnancy she described a reduction in the frequency and strength of the foetal movements. She stated: "The baby moves as if it is tired." When questioned further she said that the other babies had behaved similarly prior to the intrauterine death of the foetus. It was therefore thought that unless the baby was delivered within a short time it would die in utero like its predecessors, and that nothing more would have been achieved than in the previous pregnancies. The spur to action was the symptom of diminishing foetal movements.Accordingly, on November 27, lower segment caesarean section was performed, and a living male child weighing 4 lb. 6 oz. (2 kg.) was delivered. It was noticeably pale at birth, and the findings on examination of the cord blood were: Group 0 Rh-positive; genotype cDE/cde; haemoglobin, 4.8 g.% ; direct Coombs test positive.A replacement transfusion was given three hours after birth and 430 ml. was exchanged (100 ml. per lb.-220 ml. per kg....
