J. Selwyn Crawford

Fetal distress and the condition of newborn infants

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Improving medical meetings

SIR,-Dr Nancy Redfern reported a case of dihydrocodeine overdose in a patient with hepatic and renal impairment of unknown aetiology. It is likely that rhabdomyolysis, occurring as a result of the patient lying in a semiconscious state for a prolonged period of time and, to a lesser extent, as a result of the trauma of the assault, would have led to the biochemical abnormalities observed on the patients admission. Muscle necrosis would result in the high activities of alanine and aspartate transaminase measured, without producing appreciable abnormalities in the other indices of liver function. The discrepancy between the slightly raised y-glutamyltransferase activity and the considerably raised aspartate and alanine transaminase activities is against the presence of appreciable hepatocellular damage. There is further discrepancy between the grossly raised potassium (7 4 mmol (mEq)/l) and creatinine (614 imol/l (6-9 mg/100 ml)) concentrations and the moderately raised urea concentration (20 3 mmol/l (120 mg/100 ml)), which is characteristic of rhabdomyolysis. Rhabdomyolysis would also have contributed to the deterioration of renal function and the need for temporary peritoneal dialysis. It would be interesting to know whether other metabolic features suggestive of rhabdomyolysis were present in this patient, including a raised creatine kinase activity, myoglobinuria, hypocalcaemia, and hyperphosphataemia. Rhabdomyolysis is a more common cause of acute renal failure than was once appreciated and is probably still underdiagnosed.

Breech: vaginal delivery or caesarean section?

breech presentation at term. Factors affecting the mode of breech delivery were discussed in a recently published textbook,2 as were also the place for induction of labour and that of external cephalic version. Professor Russell mentions too the important consideration of possible litigation if all does not proceed perfectly. Clinical practices in many disciplines have changed because of the worry of possible litigation, and this, sadly, may not always be to the benefit of the public our profession serves. GERALD J AMIEL

Vasopressor Activity of Ergometrine

Moore, P. R., Evenson, A., Luckey, T. D., McCoy, E., Elvehjem, C. A., and Hart, E. B., J. biol. Chem., 1946, 165, 437. 2 Stokstad E. L. R., and Jukes, T. H., Proc. Soc. exp. Biol. (N.Y.3, 1950, 73, 523. Luckey, T. D., Gordon, H. A., Wagner M, and Reyniers, J. A., Antibiot. and Chemother., 1956, &, 37. Gordon, H. A., Wagner, M., and Wostmann, B. S., Antibiot. Ann., 1957, 248. Forbes, M., Park, J. T., and Lev, M., Ann. N.Y. Acad. Sc!., 1959, 78, 321. Coates, M., personal communication. Luckey, T. D., in Antibiotics, Their Chemistry and Non-medical Uses, 1959, chapter 3, edited by H. S. Goldberg and D. van Nostrand, Princeton, New Jersey. Nickell, L. G., in Antimetabolites and Cancer, 1955, p. 129, edited by C. P. Roads. A.A.A.S., Washington, D.C. Luckey, T. D., Nature (Lond.), in press.