SEQUELS OF UNWANTED PREGNANCY

678 instances where the potential donor has expressed a clear view on the matter during life, the question becomes com-

paratively simple

to answer.

If therefore cadaveric organ transplantation is to continue (and, at least as far as kidney transplantation is concerned, the results fully justify its increasing use) then it would seem appropriate to promote a campaign to encourage all members of the public to make a personal decision on this subject during life, and to impart this to their close relatives. Whilst this would not solve the difficulty of removing organs when death has been sudden and the relatives are not readily available, it would at least avoid the distasteful and impractical aspects of any form of official registration, or the carrying of cards providing appropriate instructions in the event of sudden death. There can be little doubt that the most acceptable form of organ donation should have a personal and voluntary basis, and in these respects the existing Law in this country is inadequate. However, if wide public education on the lines suggested could be achieved, it seems possible that the difficulties of present legal requirements would become less important. D. L. CROSBY Cardiff Royal Infirmary, W. J. C. THOMAS. Cardiff CF2 1SZ.

EXERCISE-INDUCED ASTHMA SIR,-We are interested in the single case of exercise-induced asthma reported by Dr. Rebuck and Professor Read (Aug. 24, p. 429) and in the explanations they suggest. There is no doubt that the occasional dramatic example excites great interest and demands explanation but we should like to remind readers that it is by no means unusual, in that it can be demonstrated in most asthmatic subjects if they are able to exercise sufficiently. We1 have also shown a slight rise in airways resistance after exercise, in normal subjects, which follows the same timecourse as that observed in asthmatics. This suggests that neither increased lung volumes nor hypercapnia are necessary prerequisites. Although we have not carried out these measurements routinely, we can state that some of our best examples have had normal resting lung volumes and arterial-blood gases. The criticism that serial measurements of blood-gas tensions have not been made (or at least published) over the postexercise period, when the asthmatic attack is developing, is more valid. We have too readily accepted the view that bloodgas tensions and pH remain stable on exercise in normal or only slightly disabled subjects. McHardy and Riley2 have demonstrated a rise in hydrogen-ion concentration, due to acid metabolites, which occurs during exercise in normal subjects and continues to rise to very high levels during the first 10-15 minutes of recovery before gradually returning to normal. McHardy3 has drawn our attention to the similarity between the time-course of these changes and that of the rise in airways resistance after exercise, and this clearly deserves investigation. That voluntary hyperventilation can induce an attack of asthma certainly does not, as Dr. Rebuck and Professor Read say, dispose of the hypothesis that some bronchoconstricting humoral agent is released on exercise. Hypocapnia resulting from hyperventilation has been shown to increase airways resistance in normal subjects,4 and it is not surprising if this is shown in asthmatics in greater degree. Asthmatics are notoriously sensitive to any stimulus, whether reflexly or chemically mediated, and to demonstrate one mechanism is not to exclude the others. An important objection to the suggested mechanism of reflex bronchoconstriction, stimulated by movement of the bronchial walls during exercise, is the time-course of events. In some subjects bronchoconstriction is delayed for a minute or two after exercise and in most it does not reach its maximal effect 1.

2. 3. 4.

McNeill, R. S., Nairn, J. R., Millar, J. S., Ingram, C. G. Q. Jl Med. 1966, 35, 55. McHardy, R., Riley, R. L. Bull. Johns Hopkins Hosp. 1967, 120, 170. McHardy, R. Personal communication. Sterling, G. M. Clin. Sci. 1968, 34, 277.

for several minutes. This is a slow reflex and its prolongation cannot be explained by repeated forced-expiratory-volume measurements, because improvement eventually occurs even though the measurements continue. We ourselves, however, cannot yet offer a more convincing explanation for this intriguing phenomenon, which is now starting to attract the interest it deserves. R. S. MCNEILL JEAN R. NAIRN Therapeutics Unit, J. S. MILLAR Maryfield Hospital, C. G. INGRAM. Dundee.

&agr;-ADRENERGIC BLOCKER FOR ADRENALINE-AEROSOL ABUSE ? SiR,ŃIn the exhaustive discussion about the increase in mortality from asthma perhaps one fact has not been stressed enough. Although all kinds of sympathomimetic aerosols are bronchodilators, their effect on the pulmonary vessels may not be so uniform. While isoprenaline causes pulmonary vasodilatation,’ the local application of adrenaline, a constituent of a number of aerosols, could very well have a vasoconstrictive effect on the lung vessels. This effect could be a great menace to the hypoxxmic and acidotic asthma patient, for many studies2 have shown that the combination of acidosis and hypoxasmia is an extremely strong stimulus to pulmonary vasoconstriction, and, when that condition is intensified by a local vasoconstrictive agent (adrenaline aerosol), unforeseen reactions could be a likely consequence. Thus an ex-adrenergic blocking agent (phenoxybenzamine, tolazoline) might be used for the treatment of a severe asthmatic with possible adrenalinespray overdosage. The vasoconstrictive but not the bronchodilatory effect of the adrenaline is blocked by such drugs. Pædiatric Department, St. Radboud Hospital, J. BOON. University of Nijmegen, The Netherlands.

SEQUELS

OF UNWANTED PREGNANCY

SIR,-Iam interested in Professor McLaren’s comments last week (p. 632) on the article from University College Hospital by Dr. Tredgold and his colleagues (Aug. 31, p. 501). I take it that his statement about german measles and abortion refers to the period before the new Act, otherwise it would be irrelevant. One can only admire Professor McLaren’s courage in openly avowing the carrying out of such morally justifiable abortions, though the legal position at that time did not allow such procedures. Such situations cause considerable moral dilemmas. I have often been faced with an unhappy patient in whose case compassionate humanity cried out for termination of her pregnancy, which was clearly in the best interests of herself and her family, yet, being unable conscientiously to affirm that there really was a serious threat of mental illness, such as the Law then required, I had either to reject termination or to take part in the procuring of a criminal abortion. That the latter could not be proved against me, because only I can know what my honest clinical judgments were, does not affect the dilemma: is it morally permissible to commit a crime for a good end ? Can an act be both good and criminal-especially in a free society in which change can be brought about in the Law by persuading society of its rightfulness ? My other point of interest is Professor McLaren’s expression of surprise about the idea of abortion "to curesocial stigma’ orlack of emotional support’". Apart from the fact that this indicates a complete misunderstanding of the passage in which this is discussed, which deals with contributory xtiologid 1. 2.

Tai, E., Read, J. Thorax, 1967, 22, 543. Brody, J. S., Stemmler, E. J., Dubois, A. B. J. clin. Invest. 1967, 46, 1040. Liljestrand, G. Acta physiol. scand. 1958, 44, 216. Enson, Y., Giuntini, C., Lewis, M. L., Morris, T. Q., Ferrer, M. I., Harvey, R. M. J. clin. Invest. 1964, 43, 1146. Rudolph, A. M., Yuan, S. ibid. 1966, 45, 399. Lloyd, T. C. J. appl. Physiol. 1966, 21, 358.

679 one gets the impression that the idea of such concepts having medical significance seems foreign to him. No wonder he wants to rely on psychiatric support in deciding such questions. But this is wrong. Psychiatrists do not have a monopoly of ordinary understanding of humanity. And if any individual gynaecologist feels that he is alien from appreciation of the human predicament he can surely rely upon the family doctor for this. The proper sphere of the psychiatrist, in my opinion, is to assess those cases in which there are real grounds to suspect a danger of actual psychiatric illness, and those in which there are grounds to fear that abortion may be harmful psychiatrically (e.g., cases of neurotic rejection of pregnancy). The Law now allows abortion to be carried out to prevent a general deterioration in the patient’s mental-health standards, the likelihood of which can be assessed more reliably by the family doctor, with first-hand knowledge of the family and its social and economic setting, than by the psychiatric specialist in his clinic.

factors,

West Middlesex Hospital, Isleworth, Middlesex.

L.E. CELLS AFTER ORAL CONTRACEPTIVES

SIR,-Dr. Schleicher reported1 positive L.E.-cell tests in ten women who were receiving Ortho-Novum’ (norethisterone 10 mg., mestranol 0-06 mg.), Enovid ’ (norethynodrel 5 mg., mestranol 0-075 mg.),’Ovulen-21 ’ (ethynodiol diacetate 1 mg., mestranol 0-1 mg.), or’C-Quens’ (mestranol 0-08 mg., chlormadinone acetate 2 mg.) for 6 months to 3 years. The patients had no prior history of rheumatic disorders, and when

pills were discontinued the L.E. cells disappeared within 4-8 weeks. Dr. Pimstone2 subsequently mentioned a case which he had reported earlier of a woman who had an exacerbation of systemic lupus erythematosus while taking oral contraceptives. On withdrawal of the drug and a short course of steroids, she improved and remained in remission. In view of this and of our interest in drug-induced lupus, we studied thirty women who were being followed in the family-planning clinic of the Los Angeles County-University of Southern California Medical Center. The patients were unselected. The two drugs used were’ Ovulen ’, taken for 20 days of the cycle by twenty-two patients, and chlormadinone acetate 0-5 mg. (’ Syntex’), a synthetic progesterone-like derivative, taken without cessation by eight patients. We tested for L.E. cells by the heparinised-glass-bead and the rotated-and-washed-clot methods,3 antidesoxyribonucleoprotein (anti-D.N.P.) and antiD.N.A. by the immunofluorescent-spot method,4 and rheumatoid factor by the latex-fixation method. The table below summarises the results. L.E. cells were not found in any patient. Anti-D.N.P. was observed in one symptom-free patient, and rheumatoid factor in another with a strong family history of rheumatoid arthritis. The tests used in this negative study are very sensitive for detecting the presence of serological abnormalities. In a recent investigation one or more of these reactions was positive in the

Schleicher, E. M. Lancet, 1968, i, 821. Pimstone, B. L. ibid. p. 1153. Dubois, E. L. (editor) Lupus Erythematosus. A Review of the Current Status of Discoid and Systemic Lupus Erythematosus and Their Variants; p. 302. New York, 1966. 4. Friou, G. J. in Laboratory Diagnostic Procedures in the Rheumatic Diseases (edited by A. S. Cohen); p. 114. Boston, 1966. 5. Cathcart, E. S. ibid. p. 96. L.E.

CELLS, ANTIDESOXYRIBONUCLEOPROTEIN

(ANTI-D.N.P.),

This study was supported by National Institute of Arthritis and Metabolic Diseases grant AM-09703. Section on Rheumatic Disease and Immunology, Department of Medicine, and Section on Obstetrics and Gynecology, University of Southern California Medical School, Los Angeles, California 90033.

EDMUND L. DUBOIS LORRENE STRAIN MITA EHN GERALD BERNSTEIN GEORGE J. FRIOU.

AUTOIMMUNE DISEASE IN NIGERIANS

F. P. HALDANE.

1. 2. 3.

seventeen (77%) of twenty-two symptom-free patients receiving procainamide .6s Consequently, if a significant number of patients developed antibodies while taking contraceptive pills, there should have been a far greater incidence of serological changes noted by the methods which we used. In conclusion, we have been unable to confirm any evidence of antinuclear antibodies induced by these contraceptive drugs, using sensitive serological tests.

SIR,-Iread the preliminary communication by Dr. Greenwood (Aug. 17, p. 380) with interest. The full report by Dr. Greenwood and his colleagues on the incidence and manifestations of rheumatoid disease among Nigerian villagers "

will be of great value to students of diseases-that-do-nothappen-in-Africans ". Further baseline research on the delayed immune, or lymphocyte-mediated, response is urgently needed if we are to begin to understand why severe rheumatoid arthritis is rare or why Hashimoto’s thyroiditis has not yet been recorded in the African. There is a growing number of publications on the subjects of malarial immunity and the immunology of Burkitt’s tumour but little is known about conditions which, like rheumatoid arthritis or thyroid disease, can be directly compared with Caucasian counterparts both clinically and serologically. Only by studying disorder whose distribution is known with some certainty can sterile debate, such as that introduced by Dr. Shrank (Aug. 31, p. 513) on the alternative merits of a rare and incompletely surveyed skin complaint, be avoided. Tissue-transplantation surgery is rarely, if ever, performed in tropical Africa, but it would seem prudent to try to learn a little about the reactions of the African lymphocyte in health and disease before the first cardiac transplantation is performed for endomyocardial fibrosis. Dr. Greenwood is to be congratulated for raising some interesting questions. Medical Research Laboratory, P.O. Box 30141,

Nairobi, Kenya.

J. R. TAYLOR.

DEATH DURING THERAPEUTIC STARVATION SIR,-Dr. Drenick’s suggestion (Sept. 7, p. 573) that the fatal outcome in two of my patients treated for obesity by starvation might well have been an unfortunate coincidence has a certain appeal, especially when one considers the almost total lack of fatalities in other reported series. He also mentions increased sensitivity to drugs in the fasting state, as did Dr. Mount (July 6, p. 44), and this is a definite possibility, even though the evidence in favour is slight. Although both patients 6.

Molina, J., Dubois, Unpublished.

ANTI-D.N.A.,

CONTRACEPTIVES

E. L.,

Bilitch, M., Gierson, H. W., Friou, G. J.

AND RHEUMATOID FACTOR IN

30 PATIENTS

ON ORAL