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CONTRACEPTIVE TECHNIQUE
401 25 35
CIRCUMCISION "
SIR,—Much as I appreciated last week’s essay circumcision," I must object to the statement that Rabbinical circumcision is safe ; nor do I consider it on
satisfactory.
About two months ago I spent a considerable portion of one evening transfusing an infant circumcised by an expert Rabbi. The hæmorrhage had to be controlled in the operating-room and the baby was hospitalised for two days. Subsequent examination revealed a perfectly normal blood picture. I know of other cases needing transfusion under the same conditions, and I have seen several babies considerably anæmic owing to the insidious loss of blood which is easily overlooked for several hours. When properly handled the Gomko clamp gives excelIt is used quite lent results in the newborn period. Rabbis but is not also, widely by permitted by orthodox Jews. P. G. BANISTER. Oxford, INTRA-ARTERIAL TRANSFUSIONS SiR,-The apparatus described in 1941, to which Dr. A. Mackenzie and Dr. W. W. Mushin refer, was unknown to me owing to wartime conditions. Dr. Mackenzie says that the apparatus described by me2 ia "essentially similar." This, however, is not correct. Drip chamber and glass float form only a part of my apparatus. In addition, it includes a blood filter and is designed for intra-arterial injections during transfusion. Furthermore it is so constructed that all parts can be easily detached and separately cleaned. " According to Dr. Mushin the older outfit has become widely known in this country, if not the world since 1941. Yet I could not find this apparatus mentioned either in any recent publication on intra-arterial transfusion or in the American manual on blood-transfusion by DeGowin et al.3, which discusses modern transfusion techniques in great detail. HARRY SCHAEFFER. Alexandria, Egypt. "
E.C.T. MODIFIED BY SUXAMETHONIUM SIR,-I am grateful to Dr. Adderley and Dr. Hamilton for correcting an impression they gained, from reading my article (July 18), that electroconvulsive therapy (M.T.) is ever completely contra-indicated. I did not ay so. I said that treatment was avoided whenever in certain cases, and I summarised the position as follows : Suxamethonium has enabled the benefits ofE.c.T. to reach every mental hospital patient. There u no complete contra-indication." 1 prefer not to treat cases of recent fracture because there may be slight leakage of suxamethonium from the vein and a fully paralysing effect may not have been produced. This occurred twice in 12 treatments recorded ty Adderley and Hamilton.4 It is hard to see how inhalation of septic material from teeth or gums can be avoided in a completely paralysed patient being artificially respirated without rotating the patient on to his side. It is the paralysis rather than the depth of sleep that disables the swallowing reflex. I prefer not to treat cases of recent coronary thrombosis because I feel they may be more liable to syncopal death from vagal stimulation, and since writing my article I have had such a death in a hypertensive patient with coronary disease. The smaller hypertensive effect in the treatment I use is due to a smaller dose of suxamethonium—
possible
"
1. 2.
Lancet, 1953, i, 1048. Ibid, p. 952.
3. DeGowin, E.L., Hardin, R. C., Alsever, J. B. Blood Transfusion. Philadelphia and London, 1949. 4. Adderley, D. J., Hamilton, M. Brit. med. J. 1953, i, 195.
mg.
avoidR the lnay
compared with 75 ing. This lower dose of liyl)otoitsive agents which themselves
use
cause
syncope. and Hamilton state that they have never seen prolongod apnœa and they think that it is caused by an unsuitable technique. Prolonged apnoea has been reported by so many observers that this statement must have amazed many anæsthetists. It is another reason why I prefer to keep to smaller doses of suxamethonium. I do not think I have overestimated the dangers of treatment and I hope that the letter by Dr. Adderley and Dr. Hamilton will not induce a lack of caution in this matter. G. I. TEWFIK. Middlewood Hospital, Sheffield.
Adderley
CONTRACEPTIVE
TECHNIQUE
SIR,—Dr. M. 11. Jackson’s letter last week regarding the use of ’Preceptin ’ is timely. The wide advertising of this product as giving " dependable conception control without a diaphragm " is to be deplored. As Dr. Jackson suggests, the product will find its own level of usefulness for couples to whom the birth of a, child would not be a serious matter, but where the health of the mother, or the welfare of the family, demands maximum safety in the method of contraception, the Family Planning Association is still of the opinion that a chemical contraceptive and a mechanical barrier areessential. JOSEPHINE BARNES Chairman, General Medical Subcommittee, Family Planning Association.
London, S.W.1.
SIR,—Having just encountered another unfortunate failure with ’Preceptin Vaginal Gel,’ despite the fact that the young woman concerned assiduously followedthe instructions of the physician who specifically recommended this method to her, I feel bound to venture on a little simple arithmetic. According to the makers of preceptin the efficacy of their product, based on American evidence, is of the order of 97-9%, 98-2%, and 98-6%. Whether this applies to persons or, rather, to coitions, is not made at all clear. If the latter, as I suspect, then the average failure-rate is one for every fifty intercourses. Using now the data of Dickinson,l the most common frequency with which married couples in the United States indulged in coitus was two to three times per week. It looks, therefore, as though the average American wife using preceptin vaginal gel will find herself pregnant twice a year ; or, allowing for the pregnancy and puerperium which, it appears, will inevitably follow, have a child once every year or so. ROY GOULDING. London, S.E.1. REACTIONS TO PENICILLIN
SIR,—In your leading article of July 11you said : In Great Britain penicillin is not available to the publicin chewing-gum and toothpaste, for example-as it is in America. This is a wise provision, and it places squarely on doctors the responsibility for seeing that patients are not needlessly exposed to the risk of sensitisation to penicillin "
and other antibiotics from their use for trivial infections-or for no real reason." This statement is not only misleading but inaccurate-
for the
following
There is
reasons :
penicillin toothpaste available. There is (1) penicillin toothpowder, but it is sold only on prescription. Chewing-gum and a number of types of troches are also available, but again only on prescription. As a matter of fact, there is not a single penicillin preparation that may be legally sold in the United States for human use without a physician’s prescription. (2) Products such as penicillin toothpowder and troches are developed because of a demand from certain physicians no
a
1.
Ford, C. S., Beach, London, 1952.
F.
A.
Patterns
of
Sexual
Behaviour.
.
CIRCUMCISION "
SIR,—Much as I appreciated last week’s essay circumcision," I must object to the statement that Rabbinical circumcision is safe ; nor do I consider it on
satisfactory.
About two months ago I spent a considerable portion of one evening transfusing an infant circumcised by an expert Rabbi. The hæmorrhage had to be controlled in the operating-room and the baby was hospitalised for two days. Subsequent examination revealed a perfectly normal blood picture. I know of other cases needing transfusion under the same conditions, and I have seen several babies considerably anæmic owing to the insidious loss of blood which is easily overlooked for several hours. When properly handled the Gomko clamp gives excelIt is used quite lent results in the newborn period. Rabbis but is not also, widely by permitted by orthodox Jews. P. G. BANISTER. Oxford, INTRA-ARTERIAL TRANSFUSIONS SiR,-The apparatus described in 1941, to which Dr. A. Mackenzie and Dr. W. W. Mushin refer, was unknown to me owing to wartime conditions. Dr. Mackenzie says that the apparatus described by me2 ia "essentially similar." This, however, is not correct. Drip chamber and glass float form only a part of my apparatus. In addition, it includes a blood filter and is designed for intra-arterial injections during transfusion. Furthermore it is so constructed that all parts can be easily detached and separately cleaned. " According to Dr. Mushin the older outfit has become widely known in this country, if not the world since 1941. Yet I could not find this apparatus mentioned either in any recent publication on intra-arterial transfusion or in the American manual on blood-transfusion by DeGowin et al.3, which discusses modern transfusion techniques in great detail. HARRY SCHAEFFER. Alexandria, Egypt. "
E.C.T. MODIFIED BY SUXAMETHONIUM SIR,-I am grateful to Dr. Adderley and Dr. Hamilton for correcting an impression they gained, from reading my article (July 18), that electroconvulsive therapy (M.T.) is ever completely contra-indicated. I did not ay so. I said that treatment was avoided whenever in certain cases, and I summarised the position as follows : Suxamethonium has enabled the benefits ofE.c.T. to reach every mental hospital patient. There u no complete contra-indication." 1 prefer not to treat cases of recent fracture because there may be slight leakage of suxamethonium from the vein and a fully paralysing effect may not have been produced. This occurred twice in 12 treatments recorded ty Adderley and Hamilton.4 It is hard to see how inhalation of septic material from teeth or gums can be avoided in a completely paralysed patient being artificially respirated without rotating the patient on to his side. It is the paralysis rather than the depth of sleep that disables the swallowing reflex. I prefer not to treat cases of recent coronary thrombosis because I feel they may be more liable to syncopal death from vagal stimulation, and since writing my article I have had such a death in a hypertensive patient with coronary disease. The smaller hypertensive effect in the treatment I use is due to a smaller dose of suxamethonium—
possible
"
1. 2.
Lancet, 1953, i, 1048. Ibid, p. 952.
3. DeGowin, E.L., Hardin, R. C., Alsever, J. B. Blood Transfusion. Philadelphia and London, 1949. 4. Adderley, D. J., Hamilton, M. Brit. med. J. 1953, i, 195.
mg.
avoidR the lnay
compared with 75 ing. This lower dose of liyl)otoitsive agents which themselves
use
cause
syncope. and Hamilton state that they have never seen prolongod apnœa and they think that it is caused by an unsuitable technique. Prolonged apnoea has been reported by so many observers that this statement must have amazed many anæsthetists. It is another reason why I prefer to keep to smaller doses of suxamethonium. I do not think I have overestimated the dangers of treatment and I hope that the letter by Dr. Adderley and Dr. Hamilton will not induce a lack of caution in this matter. G. I. TEWFIK. Middlewood Hospital, Sheffield.
Adderley
CONTRACEPTIVE
TECHNIQUE
SIR,—Dr. M. 11. Jackson’s letter last week regarding the use of ’Preceptin ’ is timely. The wide advertising of this product as giving " dependable conception control without a diaphragm " is to be deplored. As Dr. Jackson suggests, the product will find its own level of usefulness for couples to whom the birth of a, child would not be a serious matter, but where the health of the mother, or the welfare of the family, demands maximum safety in the method of contraception, the Family Planning Association is still of the opinion that a chemical contraceptive and a mechanical barrier areessential. JOSEPHINE BARNES Chairman, General Medical Subcommittee, Family Planning Association.
London, S.W.1.
SIR,—Having just encountered another unfortunate failure with ’Preceptin Vaginal Gel,’ despite the fact that the young woman concerned assiduously followedthe instructions of the physician who specifically recommended this method to her, I feel bound to venture on a little simple arithmetic. According to the makers of preceptin the efficacy of their product, based on American evidence, is of the order of 97-9%, 98-2%, and 98-6%. Whether this applies to persons or, rather, to coitions, is not made at all clear. If the latter, as I suspect, then the average failure-rate is one for every fifty intercourses. Using now the data of Dickinson,l the most common frequency with which married couples in the United States indulged in coitus was two to three times per week. It looks, therefore, as though the average American wife using preceptin vaginal gel will find herself pregnant twice a year ; or, allowing for the pregnancy and puerperium which, it appears, will inevitably follow, have a child once every year or so. ROY GOULDING. London, S.E.1. REACTIONS TO PENICILLIN
SIR,—In your leading article of July 11you said : In Great Britain penicillin is not available to the publicin chewing-gum and toothpaste, for example-as it is in America. This is a wise provision, and it places squarely on doctors the responsibility for seeing that patients are not needlessly exposed to the risk of sensitisation to penicillin "
and other antibiotics from their use for trivial infections-or for no real reason." This statement is not only misleading but inaccurate-
for the
following
There is
reasons :
penicillin toothpaste available. There is (1) penicillin toothpowder, but it is sold only on prescription. Chewing-gum and a number of types of troches are also available, but again only on prescription. As a matter of fact, there is not a single penicillin preparation that may be legally sold in the United States for human use without a physician’s prescription. (2) Products such as penicillin toothpowder and troches are developed because of a demand from certain physicians no
a
1.
Ford, C. S., Beach, London, 1952.
F.
A.
Patterns
of
Sexual
Behaviour.
.