162

diphtheria, as a procedure of national importance,should be carried out upon national, not parochial,lines. The Government should provide a standardantigen, lay down a standard dosage and insist uponchildren of pre-school age being given precedence.The taxpayer who is-providing the tools has a right to the assurance that they are being properly used.And by the winter a preventable disease will havebeen prevented.

DANGERS OF BREECH DELIVERYONE of the changes in obstetric practice in the last

ten years or so has been the almost universal adoptionof external cephalic version as a means of avoidingthe difficulties and dangers of breech delivery. Onthe wisdom of this there is little dispute, though theprocedure itself is not devoid of risk. But there arestill differences of opinion about policy and techniquewhen version is impossible and the foetus must bedelivered by the breech, as was lately demonstratedin our correspondence columns Some years agoGIBBERD’s analysis of the results obtained in fourLondon and four provincial teaching hospitalsfocused attention on the danger to the foetus of breechdelivery. His views perhaps erred on the side of

pessimism, but there is no doubt about his maincontention-that the foetal mortality of breech

delivery, especially in primigravid women, was muchhigher than was generally supposed. The figure of25-30% reported by GAIRDNER and the JACKSONS,2 from their analysis of hospital and private cases inwhich version failed and a full-sized infant was

delivered vaginally, is by no means exceptional.As CHASSAR MOIR 3 puts it, a patient about to havealmost any standard major operation-for example,the removal of a pituitary tumour-faces a betterchance of survival than does a full-sized foetus of aprimigravid woman which is about to be extractedbreech first by a doctor of average experience. Butthis picture is not always true ; individual workershave been able to reduce the mortality of their breechdeliveries to a very low level. Thus BURNS andMAYEUR 4 can report a combined foetal and. neonataldeath-rate at the Liverpool Maternity Hospital ofonly 6-2% (3-7% when strictly analysed). Stillbetter results are reported by E. M. HANSEN 5 ofNebraska-omitting deaths due to prematurity,malformation and placenta praevia, a fcetal mortalityof 0-8% in 126 private cases. This figure would begood for normal delivery, and indeed I. W. POTTER 6of Buffalo, famous for his method of conductingpodalic version, and with experience of many thousandsof breech extractions, claims that his foetal mortalityis little greater than that of normal birth. These

examples show that experience counts for more inbreech delivery than in almost any other obstetricoperation. But while the rough ways can be madesmooth, experience is dearly bought, and to the

average practitioner breech delivery remains an

anxious and uncertain event.Breech presentation is often the visible sign of other

abnormality—contracted pelvis, malformed fœtus,1. Gibberd, G. F. Brit. med. J. 1931, 1, 369.2. Gairdner, A., Jackson, M. H. and Jackson, L. N. Lancet, 1941,

1, 273.3. Ibid, 1936, 2, 1226.4. Burns, J. W. Ibid, 1941, 1, 432 ; Mayeur, M. Ibid, p. 585.5. Amer. J. Obstet. Gynec. 1941, 41, 575.6. Place of Version in Obstetrics, St. Louis, 1922.

placenta praevia and so on-and much of the successof individual workers lies in skilful antenatal detectionof underlying abnormalities. Long experience hastaught POTTER to recognise the case in which breechdelivery is safe and sure, and he makes no secretof the fact that a fair proportion of his patients aredelivered by abdominal section. Paradoxically, thatproportion rises sharply in primigravid women inwhom the foetus already presents by the breech.GAIRDNER and his colleagues also advocate the freeruse of caesarean section ; and in Liverpool the opera-tion was performed in 8% of the cases. Thatabdominal delivery is justifiable for the primigravidain the last few years of reproductive life, or for thewoman of known low fertility, has long been agreed,but that the operation should be extended to includeother types of case may seem a dangerous proposition.Caesarean section carries a small but stubborn mor-

tality ; yet if there is a considerable chance that afoetal life will otherwise be lost is not this risk justifi-able ? It must also be remembered that a difficultbreech extraction often leaves the mother a damagedwoman.

The answer resolves itself into a skilful selection ofcases. Those women in whom a mechanical difficultyis likely to arise constitute less than 20% of thewhole ; if it were possible to eliminate these " sus-pects breech delivery would at once become far lessanxious and formidable. In vertex presentationsthe doctor is able by direct means to estimate the fitof the foetal head in the pelvic brim, but in breechcases no such easy means is available to test therelative sizes of passenger and passage ; prognosiscan then be extremely difficult. Here MorR,’ in hispaper on the detection of pelvic contraction, laysstress on the help to be obtained from X-ray pelvi-metry, especially from examination of the lateralview of the pelvis. X-ray cephalometry can also be _

readily applied to the head which lies in the upperpole of the uterus. MOIR urges that such examinationsshould be a routine in every breech case ; by their usethe likelihood or otherwise of mechanical difficultywould be foreseen. By this and other improvedmethods of antenatal examination much could bedone to lessen the danger of breech delivery. Caseslikely to cause difficulty can be referred to specialhospitals with facilities for operative treatment,The " easy " remainder-and they constitute the bulkof cases-can then with far less anxiety be deliveredin the patient’s own home.

NERVOUS COMPLICATIONS OF SULPHON-AMIDE THERAPY

SINCE the introduction of the sulphonamides thenerve lesions which may complicate the acute infec-tions seem to have been less rare, presumably becausemore patients with severe infections now survivelong enough to develop them, but these have to bedistinguished from the peripheral neuritis which maybe produced by the drugs themselves. Clinicallythe course of the two is different. In the septic typethe lesion is either a radiculitis, especially in strepto-coccal infections, or is confined to the ulnar or

peroneal nerve, which becomes acutely painful andtender, with paresis of the muscles it supplies. The

7. Edinb. med. J. 1941, 48, 36.

163

sulphonamides, on the other hand, produce progres-sive paraesthesiee of the extremities with muscularweakness beginning in the small muscles of the handsand feet and gradually spreading centrally, accom-panied by sensory and reflex loss ; in one or twoextreme instances there has been complete loss ofpower in all four limbs. The sulphonamide neuritiswas originally described as a rare toxic effect of sulph- -anilamide, usually after considerable overdosage,the amount given ranging from 50 to as much as130 g. With the development of the sulphanilamidederivatives, particularly p-aminobenzenesulphon-dimethylamide, case-reports have been fairly fre-

quent, and total amounts of only 12-30 g. of thiscompound have caused the trouble. The aetiologyof the neuritis is not fully understood, but experimentsin pigeons have shown that vitamin Bl will preventparalysis, and in patients undergoing sulphonamidetherapy there is a decreased excretion of vitamin B,.Unfortunately treatment of the neuritis with vitaminBl is only partly successful. All that can be done is to

stop the drug and rest the affected parts by splintinguntil the acute phase has subsided. When thereare signs of returning activity steadily increasingfaradism with remedial exercises should be given. Insevere cases recovery is slow but the ultimate prog-nosis is still good. -

The pathology of the lesions has not been ade-quately studied in the human subject-facilities arehappily rare-but much has been learnt from animalexperiment. Chickens are peculiarly liable to developlesions of the C.N.S. under sulphonamide therapy,and in them BIETER and his colleagues 1 of Minnea-polis have lately demonstrated myelin condensationwith axon swelling from this cause. Sulphanilamidewas found to be the least harmful to the C.N.S. ofthe drugs studied, the order of increasing toxicitybeing then sulphapyridine, sulphathiazole and sulpha-methylthiazole. It has been generally supposedthat the sulphonamides permeate evenly throughoutthe body tissues and fluids, with the exception of thecerebrospinal fluid,2 but in the chickens it was possibleto demonstrate selective variations in the concentra-tion of different compounds in different parts of theC.N.S. after treatment, and similar variations are

probable in man. The human sciatic nerve maycertainly show concentrations appreciably higherthan those found at the same time in-the blood, andif this is representative of other peripheral nerves themechanism of the neuritis becomes understandable.The importance of the selective distribution of sulphon-amides between blood-cells and plasma has latelybeen pointed out,3 and a study of the distributionin other organs seems worth attempting.Two groups of patients deserve special mention.

One is the small group, becoming smaller with im-proved technique, in whom an acute meningitis followsintrathecal medication. Thus, disastrous results havefollowed the intrathecal use of the highly alkalinesodium salt of sulphapyridine, and paralysis- of thecauda equina, with slow recovery, has been reportedafterother soluble compounds used in this way. Theother group includes the injuries to the gluteal or1. Bieter, R. N., Baker, A. B., Beaton, J. A., Shaffer, J. M.,

Seery, T. M. and Burton, A. O. J. Amer. med. Ass. 1941, 116,2231.

2. See Thrower, W. R. and Whitelaw, W. Proc. R. Soc. Med. 1940,33, 555.

3. See Lancet, July 26, 1941, p. 107.

sciatic nerve, particularly its external popliteal divi-sion, after careless intramuscular injections of sodiumsulphapyridine, which may produce local necrosis ;for this reason it is unwise to give more than 1 g. in333 % solution into the buttock at any one time. Ifmore must be given, it should be given intravenously.Mental disturbance more pronounced than that

commonly arising during acute fevers may be ob-served during sulphonamide therapy 4 and may be asign of overdosage. An extreme example of this wasin the patient who through an oversight received 4 g.of sulphapyridine four-hourly for three days anddeveloped acute mania. He recovered both mentallyand physically on withdrawal of the drug. Lesssevere examples of confusion are sometimes seen aftersuch moderate dosage that it seems that these

patients are peculiarly sensitive. The chances of this

complication, like others, is increased if the drugs aretaken when up and about, a practice which cannotbe too often condemned. Apart from such indis-cretions, however, there is a peculiar form of delayedcerebral depression which may follow any of thecompounds now in common use,5 though it was

originally described in connexion with sulphanilamide.The depression is characterised by inability toconcentrate or add up simple sums, with loss ofthe fine coordinating power necessary for performingacts like typing. The final prognosis of this is good,but it can be very trying while it lasts. There isno special treatment, but the amide of nicotinic acid’might be worth a trial.

THE ALLERGIC DONORLOVELESS 6 of Cornell has lately described three

cases in which hypersensitiveness, lasting several

weeks, was transferred to patients transfused frompollen-sensitive donors. If a transfusion of blood orplasma saves the patient’s life it may seem of smallmoment if the penalty is a brief inability to toleratepollen clouds, egg diet or some other common antigen,but such transference may have other implications.It is not such a rare experience to meet severe trans-fusion reaction inexplicable on any grounds otherthan the anaphylactic, and standard works on blood-transfusion warn us against the allergic donor,although they give us no very definite information asto what happens if we neglect their advice.That the hypersensitive state can be transferred by

serum injection has been known for many years.LoNGCorE and RACKEMANN found, for example, thata guineapig receiving serum from a patient withserum sickness itself became slowly hypersensitive tohorse serum. RAMIREZ described a first attack ofasthma in a man when he entered a horse-drawnvehicle two weeks after being transfused from a horse-sensitive donor. MILLS and SCHIFF, using a horse-sensitive donor, noticed that an area of the recipient’sskin, injected with horse serum some time before thetransfusion, did not at once react but graduallydeveloped urticaria two hours later. FRUGONIdescribed the injection of serum from a woman

suffering from rabbit-hair asthma into a normal childwho subsequently developed acute conjunctivitis andrhinitis whenever brought into contact with rabbits.

4. Johnstone, D. F. and Forgacs, P. Brit. med. J. 1941, 1, 772.5. See Thrower, Ibid, 1938, 2, 591.6. Loveless, M. H. J. Immunol. May, 1941, p. 15.