THE ADOLESCENT PRIMIGRAVIDA

1083 TABLE III-TOXIC MANIFESTATIONS OBSERVED IN THE 19 PATIENTS

died of infection. One

case

of

multiple myeloma did

not

respond. Toxic effects, particularly neurotoxic prominent but not permanent.

side-effects,

were

We should like to thank the members of the department of pathology, and also house-physicians, registrars, and nursing staff, at the Royal Free, Hampstead General, St. Mary Abbots, and the Royal Masonic Hospitals, who helped in the diagnosis and management of these cases. We are grateful to the photographic department of the Royal Free Hospital for the photographs of case 5, and to Dr. E. D. R. Campbell, of the department of physical medicine at the Royal Free Hospital, for the electromyelographic investigation of case 9. We are most grateful to Messrs. Eli Lilly for supplies of vincristine, and for their advice during this study. REFERENCES

paralytic ileus developed after a week’s treatment. Eight patients experienced some abdominal discomfort, but in no a

case was

it

severe.

frequent complication, appearing in nine of the nineteen patients. It was usually first noticed between the 3rd and 6th weeks of treatment. Loss of hair ceased, and Alopecia

was a

growth recommenced, in some patients who were still receiving the drug. Neurological complications were prominent. Limb paraesthesix occurred in twelve cases; they were usually accompanied by a feeling of numbness but definite subjective sensory loss was only found in one instance. Four patients showed motor weakness which was most severe peripherally. Electromyelography in case 9 showed evidence of a motor neuropathy especially in the periphery; sensory potentials were of normal latency though rather diminished in amplitude. There was complete absence of knee and ankle jerks in four patients, and hyporeflexia in another. These neurological complications appear to be reversible if the dose of vincristine is reduced. The patient most severely affected was given prednisolone 30 mg. a day, and the maintenance dose of vincristine 0-03 mg. per kg. per week was continued. Her condition has improved considerably, with return of previously absent tendon reflexes and increase in motor power. Jaw pain was a feature in three patients, and pain in the back and in the calves of the legs each occurred in one case. Weight loss of 3 kg. or more occurred in four patients, but this might well have been a manifestation of the disease under treatment. In many cases there was a significant increase in

weight during

treatment.

Discussion

Armstrong, J. G., Dyke, R. W., Fouts, P. J. (1962) Proc. Amer. Ass. Cancer Res. 3, 301. Beer, C. T. (1955) in British Empire Cancer Campaign: 33rd Annual Report, p. 487. London. Bohannon, R. A., Miller, D. G., Diamond, H. D. (1962) Proc. Amer. Ass. Cancer Res. 3, 305. Carbone, P. P., Brindley, C. O. (1962) ibid. p. 309. Cardinali, G., Cardinali, G., Enien, M. A. (1963) Blood, 21, 102. Costa, G., Gailini, S., Holland, J. F. (1962a) Proc. Amer. Ass. Cancer Res. 3, 312. Hreshchyshyn, M. M., Holland, J. F. (1962b) Cancer Chem. Rep. —

24, 39. Karon, M. R. (1962) Proc. Amer. Ass. Cancer Res. 3, 333. Freireich, E. J., Frei, E. (1962) Pediatrics, 30, 791. Neuss, N., Gorman, M., Boaz, H. E., Cone, N. J. (1962) J. Amer. chem. Soc. 84, 1509. Noble, R. L., Beer, C. T., Cutts, J. H. (1958) Ann. N.Y. Acad. Sci. 76, 882. Selawry, O. S., Delta, B. G. (1962) Proc. Amer. Ass. Cancer Res. 3, 360. Hananian, J. (1963) J. Amer. med. Ass. 183, 741. Svoboda, G. H. (1961) Lloydia, 24, 173. —

—

THE ADOLESCENT PRIMIGRAVIDA R. H. STEARN Lond., M.R.C.O.G.

M.B.

RESIDENT REGISTRAR IN OBSTETRICS AND ST.

GYNÆCOLOGY, THOMAS’S HOSPITAL, LONDON, S.E.1

THIS paper is based on experience gained in the manageof girls under 16 years of age at the time of delivery. The girls were delivered in a fifteen-month period from May, 1961, to August, 1962. Of the 30 patients, 28 were English and 2 West Indian. They were, in the main, referred from a home for adolescents. All were unmarried. The antenatal care was shared between the doctor to the home and the Lambeth ment

Hospital. The age-distribution,

at

delivery,

was as

13-14 yr....... 14-15 yr....... 15 yr. +

7 10 13

follows:

While it would be quite misleading, on the basis of this study, to claim that the malignant process treated can be The youngest was 13 years 3 months and the oldest 15 satisfactorily controlled for long, there is no doubt that years 8 months. very rapid and sometimes complete remissions can be This short series brought out four points: the high obtained with vincristine. All ten patients with lymphomas incidence of hypertension; the physical maturity of the treated enjoyed some degree of remission; five of them the speed of labour and the ease of delivery had proved resistant to other cytotoxic agents. The res- adolescents; was no stillbirth or neonatal death); and the (there ponse in the leukaemias was less satisfactory, though mental tolerance of the pregnancy. nevertheless significant. These were adult cases, however, patients’ good and better results are apparently obtained in children. A Hypertension and Pre-eclamptic Toxaemia The longer trial in the lymphomas and other tumours certainly blood-pressure when the patients were first seen was above 120 mm. Hg systolic in 10 and above 80 mm. appears justifiable. Summary Hg diastolic in 2. Nineteen cases of disseminated malignant lymphoma The systolic blood-pressure rose in 17-in 10 by 20 mm. and leukxmia were treated with vincristine sulphate, an Hg or more. The diastolic pressure rose in 13-in 7 by alkaloid extracted from the periwinkle, Vinca rosea Linn. 20 mm. Hg or more. Partial or occasionally complete remission followed in In 8 patients the blood-pressure rose to 140/90 mm. Hg all ten cases of lymphoma treated. Three cases of monoor more. Of these, 5 had other signs of pre-eclampsia-3 cytic leukxmia (Naegeli type) responded, but only one of with albuminuria and 3 with oedema. 2 patients with three cases of chronic lymphatic leuksemia responded. albuminuria and 1 with pure hypertension were induced Two cases of chronic myeloid leukaemia, which had at term. These were the only inductions in the series. All relapsed on busulphan, responded haematologically but showed little delay in going into labour. ......

1084 TABLE I-TIME OF ENGAGEMENT OF THE HEAD

There

19 forceps deliveries, 10 spontaneous vertex and 1 assisted breech delivery. There was no deliveries, caesarean section. were

Forceps Delivery

Although this is a high incidence of hypertension, in patient it was transient, settling on admission and recurring in labour in only 2. each

Labour

.

FIRST STAGE

The head failed to engage in 16 patients (plus 1 breech) before the onset of labour. Nevertheless, no cassarean sections were performed and the first stage was not

lengthened (table I). patients were delivered with when the cervix was fully dilated, the length of forceps the first stage of labour only is considered. Compared with the length of the first stage in 343 consecutive primiparae over the age of 16 delivered during part of 1962, there was no increased incidence of protracted labour. Two-thirds of the adolescents, by contrast with under half of the controls, were fully dilated within 12 Because many of the

TABLE 11-TIME TO REACH FULL DILATATION

All except 3 forceps deliveries were performed under pudendal block anaesthesia. General anaesthesia was given on 3 occasions only: (1) for protracted labour with a big baby; (2) for pre-eclamptic toxaemia; and (3) for a transverse position in a girl, aged 13 years and 7 months, who was 4 ft. 91/2 in. in height-it was an easy delivery. The forceps deliveries were assessed on whether the traction was easy, moderate, or firm. The " easy" deliveries (12) would certainly have delivered themselves if left; the " moderate " (4) would probably have delivered themselves; and the " firm " (3) almost certainly not. Only 1 patient in whom it had been decided to allow spontaneous delivery required forceps. Forceps deliveries under pudendal block were conducted in the following manner: ...

At full dilatation, an intravenous injection of pethidine (50-100 mg.) and promazine (50 mg.) was given. The patient was then placed in the lithotomy position and a pudendal block was performed, followed by catheterisation of the bladder and full vaginal examination. The forceps were then applied. The patients gave no trouble and did not become distressed. The only side-effect was a rise in pulse-rate to around 140 per minute, which returned to normal as soon as the baby was delivered. None of the patients had hypotension.

Intravenous pethidine and promazine combined with pudendal block gave excellent " anaesthesia for forceps delivery in these patients. "

a

Spontaneous Vertex Delivery hours (table n). Although the numbers are small for valid comparison, the control primiparae were in labour for over 24 hours twice as often as the adolescents. The increased speed of labour was not due to a lower birthweight of the babies (table ill). The birthweights were much the same in the two groups, which accords with the findings of Bochner (1962). 5 of the 30 patients were admitted to the labour ward with the cervix fully dilated and without having received analgesia. This high number is more characteristic of the grande multipara than of the primipara, and it illustrates TABLE III-BIRTHWEIGHT OF BABIES

the tendency of labour to be short and easy in patients of this age. Sedation with a combination of pethidine 100-150 mg. and promazine 50 mg. was given freely throughout labour.

There were 10 spontaneous vertex deliveries and 1 assisted breech. The change in the character of the pains and " bursting feeling " often caused distress to the patients and made them resist pushing. When analgesia was induced at the stage of full dilatation they cooperated well and resumed their pushing. Continued sedation with pethidine and promazine was easier than with trichloroethylene (’ Trilene ’) given intermittently. The average length of the second stage was 29 minutes. All except 1 patient had an episiotomy. THIRD STAGE

The third stage was conducted by applying the BrandtAndrews technique with the first contraction after the birth of the baby. IntramuscularSyntometrine’ (ergometrine 0-5 mg., oxytocin 5-0 units) 2 ml. was given with the crowning of the head. There was no postpartum haemorrhage. The 1 retained placenta followed a forceps delivery. Manual removal was performed under pudendal block. Mental Attitude There was little, if any, psychological upset during pregnancy or the puerperium. In labour some patients were frightened, but they settled well on sedation.

DELIVERY

decided to make the second stage as easy as possible. At first the patients were delivered with forceps as soon as the cervix was fully dilated, but at the end of the series the patients were allowed a spontaneous vertex delivery. This change was made because many of the forceps deliveries were unnecessary owing to rapid descent of the head without any evidence of bony or soft-tissue dystocia. The patients seemed to push very well, although sedation had often been given within 2 hours of full dilatation. It

was

Discussion

in young girls is not a cause for anxiety and the young mother shows an excellent capacity for maternity while the infants are of high vitality " (Caso and di Fonzo, 1950). The findings in this series confirm this statement. The only major problem was hypertension in the antenatal period. Marchetti and Menaker (1950) found that a third of all their cases had antenatal complications, 60% of which were toxaemic. The reported incidence of pre-eclamptic toxaemia has varied from 1’16% (Caso and di Fonzo 1950)

" Pregnancy

1085

28% (Mussio 1962). This variance is understandable diagnosis is made on a single reading of a systolic blood-pressure of 140 mm. Hg and/or a diastolic pressure of 90 mm. Hg or more, with or without albuminuria (Sinclair 1952). Some workers do not define toxaemia. Transient hypertension is not necessarily the same disease as pre-eclamptic toxsemia. A raised incidence of toxacmia was reported by Mussio (1962), Marchetti and Menaker (1950), Aznar and Bennett (1961), Hacker et al. (1952), Bochner (1962), Jarvinen and Katka (1959), and Arnot and Nelson (1958); but Briggs et al. (1962) and Caso and di Fonzo (1950) reported a to

if the

diminished incidence. Of the 30 patients in the present series 3 had albuminuric toxaemia and 8 had hypertension of 140/90 mm. Hg or over: all settled rapidly on admission. Hypertension recurred during labour in only 2 patients. Because of this tendency to hypertension, adolescents should perhaps be seen weekly after the 32nd week. The apparent immaturity of the adolescent presented no problem in labour. Possibly because these girls had been taken away from their families and immediate friends, no fear of labour had been instilled into them and thus one of the more potent causes of inertia was not present. The shortness of labour is probably related to a good myometrium and fully developed pelvis. Mussio (1962) states that the recognisable difference in the male and female bony pelvis that develops after puberty is marked by such rapid growth in the female that the bony portion of the reproductive canal may be adequate for the passage and birth of a full-term foetus in less than a year. This is in agreement with Greulich and Thoms (1945), who found, in studying the development of 90 girls, that change to the adult shape was quickest in those maturing early. After puberty, there was little change in size of the pelvis and none in shape. The fact that in the present series no cxsarean section was performed, although at regular antenatal visits the head was never found to be engaged, confirms the opinions of Hacker et al. (1952) and Marchetti and Menaker (1950) that cephalopelvic disproportion need not be feared. Sinclair (1952) delivered 95% of young primigravidae spontaneously. American series show a high frequency of forceps delivery-Von der Ake and Bach (1951) delivered 71 % with forceps of which 97-8% were low-outlet forceps, and Clough (1958) 82% with low forceps. These were routine forceps deliveries, most of which must have just preceded spontaneous delivery. The high frequency of forceps deliveries is not due to the difficulty of labour, but to the need to allay fear and apprehension-an unnecessary precaution in the experience of Sinclair (1952) and Fairfield (1940), who could discover no reference to unusual

anxiety, depression, or nervous instability during pregnancy, labour, or the puerperium in adolescents. Conclusions in the adolescent Pregnancy primigravida is relatively free from complication; but careful watch must be kept for hypertension and pre-eclampsia. In the present series, hypertension settled rapidly after the patients’ admission to hospital. Pregnant adolescents should ’be seen weekly after the 32nd week. Although, owing to late engagement of the head, cephalopelvic disproportion might have been expected, cxsarean sections were not necessary, and labour was shorter than in the older primigravidae.

The babies were all healthy and babies of older primiparae. There

equalled in was no

size the increase of

prematurity. When possible, delivery should be as a normal spontaneous vertex. Fear and apprehension at full dilatation may require sedation or forceps delivery. Psychologically the girls in this series seemed to stand the pregnancy surprisingly well. I should like to thank Miss L. E. Hurter and Mr. P. Rhodes for their encouragement; and Mr. P. J. Huntingford for advice iri the preparation of this paper. REFERENCES

Arnot, P. H., Nelson, D. R. (1958) West. J. Surg. 66, 332. Aznar, R., Bennett, A. I. E. (1961) Amer. J. Obstet. Gynec. 81, 934. Bochner, K. (1962) ibid. 83, 269. Briggs, R. M., Herren, R. R., Thompson, W. B. (1962) ibid. 84, 436. Caso, R., di Fonzo, N. O. (1950) Obstet. Ginac. lat.-amer. 8, 158. Clough, W. S. (1958) Obstet. and Gynec. 12, 373. Fairfield, L. (1940) Lancet, ii, 61. Greulich, W. W., Thoms, H. (1945) Yale J. Biol. Med. 17, 61. Hacker, E. M., Epperson, J. W. W., Priddle, H. D., Longyear, H. W. (1952) Amer. J. Obstet. Gynec. 64, 644. Jarvinen, P. A., Katka, O. (1959) Ann. Chir. Gynœc. Fenn. 48, 306. Marchetti, A. A., Menaker, J. S. (1950) Amer. J. Obstet. Gynec. 59, 1013. Mussio, T. J. (1962) ibid. 84, 442. Sinclair, R. St. C. (1952) J. Obstet. Gynœc. Brit. Emp. 59, 504. Von der Ake, C. V., Bach, J. L. (1951) West. J. Surg. 59, 235.

VARIOLA IN TANGANYIKA H. S. BEDSON M.B. Lond., M.R.C.P. LECTURER

K. R. DUMBELL M.D.

Lpool

SENIOR LECTURER

BACTERIOLOGY DEPARTMENT, UNIVERSITY OF LIVERPOOL

W. R. G. THOMAS SENIOR

M.B. Lond., D.T.M. & H., Dip. Bact. PATHOLOGIST, CENTRAL PATHOLOGY LABORATORY, DAR ES SALAAM, TANGANYIKA

THIS paper describes the investigation of 23 strains of variola virus isolated in various parts of Tanganyika during 1961, 1962, and 1963. Most of these strains have, in the laboratory, proved clearly different from both variola major and alastrim (variola minor). Furthermore their behaviour has been sufficiently uniform to suggest the existence of a third variety of variola virus. Such clinical evidence as is available shows that the disease caused by this kind of virus is undoubtedly mild, but it is insufficient to establish whether or not it differs from alastrim. Reliable differentiation bf the two main varieties of smallpox virus in the laboratory was first achieved by Helbert (1957), who compared 5 strains of each type taken from clinically well-authenticated outbreaks. He showed that the viruses differed in their viruence for the chick embryo, variola major being the more lethal. Unfortunately, tests based on this difference are too laborious and time-consuming for use with more than a few strains. In 1961 Nizamuddin and Dumbell showed that the viruses could be distinguished more simply by a difference in their ability to grow on the chick chorioallantoic membrane (c.A.M.) at raised temperatures of incubation. 14 strains of variola major produced pocks at 38-38’5°C whereas 10 strains of alastrim did not. With the advent of this test it became possible to examine much larger numbers of strains. Arrangements were therefore made for the collection of material from cases in many parts of the world. The experience gained with these additional strains has considerably expanded the basis for confidence in the temperature test. In particular, 23 strains from cases of clinically and epidemiologically well-attested alastrim in Brazil were found to conform to expectation (Downie et al. 1963). Although most of the additional strains have given clear-cut results in the temperature