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apparatus to respond adequately to an antigenic stimulusduring the earliest period of life. In man, Blum,13Mme Jakobkiewicz and others have noted the compara-tive failure of young infants to produce diphtheriaantitoxin after the injection of toxoid, and this is onereason why diphtheria immunisation is not recommendedas a general rule till after the sixth to ninth month.

Whooping-cough vaccine is seldom administered in theUnited States till the seventh to tenth month, althoughG. S. Wilson,14 being impressed by the high mortalityunder six months, advocates beginning the course at theend of the second or third month. In view of the

uncertainty of response at this early age it would perhapsbe wise to insist on further injections of vaccine in laterlife for these children, to re-stimulate their antibody-producing mechanism.

IMPROVING BLOOD-GROUPINGWAR-TIME activity in blood-grouping has drawn

attention to the lack of uniformity in nomenclature andtechnical methods in use among those making the tests.A paper by the Imperial Serologist in India and hiscolleagues 15 teems with suggestions for revising andstandardising practice. A worker adopting their pro-posals would have to revise his methods drastically,and his new methods would not necessarily be betterthan his old, but his diagnoses of blood-groups wouldalmost certainly be much more accurate because hewould determine not only the antigen content of a

person’s red cells but also the antibody in the serum.None of the authorities omits, unless he must, the check-test offered by examination of the serum, for following-upany anomaly should prevent all errors in diagnosis of theABO system. Before the war nearly all cliniciansused the Moss numerical classification, but more andmore of them are taking up the international alphabeticalABO nomenclature, and the use of letters for the

antigens and of " anti-A " and " anti-B " for the

agglutinins seems satisfactory and logical. To getestablished workers in a field to adopt a new terminologyis difficult, as anatomists and bacteriologists know ;and, since the great advantages of letters over numbersare being recognised and letters are being used, nothingshould be allowed to interfere with the adoption of theinternational classification as it stands. Some majoralterations in the alphabetical notation suggested by theworkers in India would not be improvements. The useof the lower case " a " and " b " for the antibodies isreactionary and was rightly condemned years ago.The Greek a and # for the antibodies are said to beunnecessary-and indeed they do not appear in therecommendations of the League of Nations Committeeresponsible for the international classification-but well-known workers in the field use them and would miss them,and they have no obvious disadvantages. The terms

" isogen " and " isonin " proposed for the isoagglutino-gens A and B and their isoagglutinins might be acceptedby some, but " haemogens " M and N for the antigens ofthe M-N system of groups would be hard for anybodywith a regard for etymology to tolerate. Much has beenwritten, mostly in America, about the harm that maytheoretically befall a transfused patient if the antigenin his red cells meets corresponding antibody in greatstrength in the donor’s plasma. The practice, recentlyintroduced, of treating shock with transfusions of largeamounts of blood, serum or plasma, or with concentratedserum or plasma, has similar possibilities. It is difficultto discover from the literature how real and how greatthis danger is, but the workers in India attach consider-able importance to it, and believe that accidents followingindiscriminate transfusion with group 0 have escaped13. Blum, J. Med. Off. 1932, 47, 245 ; Jakobkiewicz, J. Rev. Immunol.

1937, 3, 70.14. Brit. med. J. 1941, 1, 593.15. Greval, S. D. S., Chandra, S. N. and Woodhead, L. S. F. Indian

J. med. Res. January, 1941, p. 231.

detection. In their technique the strength of theantibodies in the sera of 0 donors is determined and thedonors are classified accordingly ; quite a large propor-tion are not accepted as universal donors because’theantibody content of their serum is considered to be

dangerously high. Colonel Greval strongly advocatesdirect tests of the reactions between the blood of the

recipient and that of a prospective donor, whether ofthe same or of another group. He is right in urging thatthere is room for improvement in grouping -procedure;more should be demanded of a technique than that itshould be rapidly and easily performed.

POSTURE AND THE T WAVE

THE T wave, that problem child of electrocardiography,has in recent years taken one of its excursions into therealm of clinical and physiological research. We arestill more or less ignorant of its significance and cause,but information is accumulating. One of the earliestfacts known about it was that it altered with changes ofposture, becoming inverted when the subject stood up.This inversion has been attributed by some to ortho-static anaemia of the heart, or to a faulty myocardium,while others regard it as normal. Scherf and Weissberg 1have been at the puzzle again. Of the 35 subjects, aged20-30, with normal cardiovascular systems whom theyinvestigated, nearly all showed an inversion of T in oneor more leads on assuming the erect position; this changewas most consistent in leads 2 and 3. It made littledifference whether the electrocardiogram was taken

immediately on the assumption of the erect position orafter standing for 12 minutes ; and in 28 instances inwhich an electrocardiogram was taken as soon as thesubject lay down the T wave immediately returned to itsoriginal height and configuration. This last observation

suggests that the changes are not due to orthostaticanaemia or coronary insufficiency ; moreover the Twave became higher after exercise in the erect positionand lower after the administration of nitroglycerin.On the other hand they found that the inversion of Tproduced on standing was exaggerated at the end of fullinspiration, while with full expiration in the same

position the inverted wave became smaller. They suggest,with good evidence, that inversion of the T wave onstanding up is due to the change in the position of theheart in relation to the diaphragm and neighbouringtissues. This means that the position of the patientwhile electrocardiograms are being recorded is important;unless the patient is lying down inversion of T, especiallyin leads 2 and 3, may be found even where the cardio-vascular system is normal. The routine adoption of thesupine position would reduce considerably the number ofcases in which inversion of T leads to confusion indiagnosis. The relationship between these electro-

cardiographic findings and postural hypotension-thecondition in which a sudden fall of blood-pressureaccompanied by loss of consciousness occurs on standingup-is worth considering. According to Stead andEbert 2 the primary factor in this condition is a loss ofthe reflex vasoconstriction which normally maintainsthe arterial pressure when people stand up. Byexperi-ment they have shown that three patients with posturalhypotension did not pool more.blood in the lower partof the body on standing than normal subjects; but thatpooling of the normal amount of blood caused anabnormal fall in blood-pressure. They suggest that theprimary lesion lies in the sympathetic nervous system,though whether centrally or peripherally remainsindefinite. On the whole they think that the lesion islikely to be in the sympathetic centres, or their efferenttracts in the central nervous system. Their results

1. Scherf, D. and Weissberg, J. Amer. J. med. Sci. 1941, 201,693.

2. Stead, E. A., Jun., and Ebert, R. V. Ar intern. Med. 1941,67, 546.

46

run counter to the suggestion of Maclean and Allen,3that postural hypotension is due to an inadequate returnof venous blood to the heart. It would have been ofinterest to know the electrocardiographic findings inStead and Ebert’s patients, even though Scherf andWeissberg found that in their cases the T wave changesand the blood-pressure were not correlated. It is perhapsimprobable that any correlation would be found in

patients with postural hypotension ; yet if a change ofposition of the heart can cause electrocardiographicchanges in the normal subject it might well affect evenmore decidedly the chemistry, electrical potentials andfunctioning of the myocardium in patients with anautonomic disturbance.

PAROXYSMAL TACHYCARDIA IN INFANTS

To count the pulse accurately in young infants is ;notoriously difficult. This may well account for the

paucity of case-reports of abnormally rapid pulse-ratesdue to abnormal states of cardiac function. Thus J. P. :Hubbard 4 of Boston, was able to find only -19 ieportedcases of paroxysmal tachycardia or auricular flutter in infants less than one year old in whom the rates wereestablished by polygraph or electrocardiographic records.He reports 9 cases of his own, however, 6 of which were i

observed in one year, and the graphic clinical picturehe draws should enable others to detect this interestingabnormality. In all 9 cases the ventricular rates varied ifrom 220 to 305, demonstrated electrocardiographically ;in 7 of them the age of onset was within the first month oflife, one case being noted on routine examination of ababy aged ten days on its discharge from a maternityunit. Cases have in fact been reported of abnormalrates noted before birth. The tachycardia may be Iassociated with some other illness, possibly birth trauma, Ior may start for no obvious cause. If it continues, ;congestive failure develops with symptoms which mayfirst draw the attention of the parents or doctor to the 1

fact that the baby is ill. The clinical syndrome is ;

characteristic : vomiting occurs and may be severe

enough to suggest pyloric stenosis ; the baby becomes Jlimp and has a dusky, greyish colour. The heart is 4

found to be beating at a rate which is often too fast to becounted and the radial pulse is as a rule imperceptible. J

The heart enlarges rapidly, severe dyspncea ensues with a 4

respiratory rate which may mount to - 150-160 perminute. The liver becomes engorged and its edge may Jbe felt as low as the iliac crest. (Edema of dependentparts may develop. The temperature usually rises and 4

there is a leucocytosis. The attack may stop -spontane- 4

ously, but is likely to proceed to a fatal termination 4unless digitalis is given promptly. Hubbard uses ]

Digifoline, giving an initial dose of 0-05-0-1 g. intra- ;

muscularly and repeating it until the desired effect isobtained. One baby, weighing 9 lb., required 0-3 g. of ;

digifoline in the course of two days before the cardiac 4condition was controlled. Once digitalisation is achievedthe heart promptly returns to a normal rate and rhythm.The temperature and respiratory rate also return rapidlyto normal, the heart decreases in size and the liver edgeshrinks back to the costal margin. There is often ,

considerable diuresis with consequent loss of weight;the colour and general condition of the child usuallyshow a striking improvement. Hubbard’s electro-cardiographic records show a tachycardia of supra-ventricular origin; in no case was there evidence ofauricular flutter. After effective treatment there wereshort recurrences in a few cases, but eventually theseceased ; as far as a relatively brief period of follow-up(six months at least) showed there was no tendency forthe condition to persist. Attacks similar to those

3. Maclean, A. R. and Allen, E. V. J. Amer. med Ass., 1940, 115,2162; and see Lancet, March 22, 1941, p. 387.

4. Amer. J. Dis. Child. 1941, 61, 687.

described might be mistaken for pneumonia -or an acuteinfection, but complete examination should establish therapid onset of heart failure with severe tachycardia ; theresponse to digitalis should clinch matters.

ANOTHER USEFUL SULPHONAMIDE

SULPHAMIDOTHIAZOLE (Cibazol or Ciba 3714), a nearrelation of sulphapyridine, has lately been recommendedfor a variety of infective conditions by a group of Swissworkers. W. Brunner and E. Schliipferl have used thiscompound in powder form in the local treatment of 109potentially infected wounds of various types. Of these,106 healed by first intention ; there were no alarminginflammatory or other reactions in any instance, nor didhealing appear to be retarded. Necroses and haematomaswere rarely observed in the wounds. Amounts of thepowder varying from 0-3 to 3-8 grammes were-usuallyinstilled, and in some cases, where there was no obviousrisk of infection, a depot of the powder was establishedin the wound. Apart from this the treatment was of thesimplest surgical character and no attempts were madeeither to excise the wound or to secure immobilisationin the healing stages. Portions of tissue excised for

bacteriological examination before and immediately afterthe instillation of cibazol showed a pronounced falling offof positive cultures in the latter. Cibazol has been givenby mouth or by intramuscular or intravenous injectionin obstetric and gynaecological cases by H. Winzeler.2As a prophylactic agent in normal- childbirth the resultswere inconclusive, but in 40 patients in whom manipulativeinterference complicated childbirth the results suggestedthat, when started immediately after parturition, thisform of medication was of definite benefit, the criterionof usefulness being the temperature chart. In thesecondary febrile complications of pregnancy, such aspuerperal endometritis and mastitis, the effects wereunconvincing. Winzeler observes that, in a total of 200treated cases, doses of up to 60 g. are well tolerated,especially when given by mouth. No harmful reactionswere noted even after intramuscular and intravenousinjections. Laboratory analyses showed no damage toeither the renal or h2emopoietic systems. J. Flagg andP. Koenig 3 have applied cibazol locally in the form offlexible pencils containing 10% of the sulphonamide forcervical endometritis. In 23 cases of varied aetiologywhich received regular treatment the discharge ceased orimproved in the majority. It is not clear from the reportwhether these good effects were maintained after thecessation of treatment; the series is too small to affordconclusive results but suggests the desirability of furtherinvestigations. Lastly A. Schnieper 4 records the bene- ‘ficial effects of cibazol as an ointment, containing 5%of the active agent, in pus-coccal infections of the skin.He found it especially valuable in the treatment of thecommoner forms of impetigo, in 15 cases of which theeruption cleared up within 5-10 day’s and improvementwas obvious within 12-24 hours of starting treatment.

Dr. PAUL FILDES, F.R.S., has been appointed a memberof the governing body of the Lister Institute, in placeof the late Prof. William Bulloch.

Sir WiLLiAM WILLCOX, consulting physician to St.’Mary’s Hospital, Paddington, died at his London home onJuly 8. We also regret to announce the death on Jifty 5of Dr. DouGLAS STANLEY, emeritus professor of pharma-cology and therapeutics in the University of Birmingham.Professor Stanley was at one time editor of the Birmingham3ledical Rr;.view, which has this week lost one of its moststimulating writers through the death of Dr. F. G.LAYTON on July 3.

1. Schweiz. med. Wschr. March 8, 1941, p. 213.2. Ibid p. 217. 3. Ibid p. 220. 4. Ibid, p. 222.