INTRAPERITONEAL POVIDONE IODINE

37 MEAN BIRTH-WEIGHT

(g) OF SINGLETONS IN RELATION TO

MATERNAL SMOKING

that blood-alcohol concentrations legal limit". M.R.C. Industrial Injuries and Burns Birmingham Accident Hospital, Birmingham B15 1NA

can

actually

"fall below the

E.

J. L. LOWBURY

Unit,

WOUND SUTURE AFTER APPENDICECTOMY

SIR,-Mr Foster and his colleagues (May 28, p. 1128) have the results of interrupted nylon skin sutures with subcuticular polyglycolic acid (P.G.A.). They found that subcuticular P.G.A. was significantly more commonly associated with wound sepsis, and concluded that "subcuticular skin suturing cannot be recommended as a method of closure after appen-

compared

dicectomy". Although Mr Foster and his colleagues suggest that a prospective trial comparing different types of material might be carried out, I think that their conclusion criticises the method of suture rather than the material. In my unit for a number of years abdominal incisions have been closed either with subcuticular P.G.A. or with subcuticular polypropylene (’Prolene’). Prolene has given significantly less inflammatory reaction than P.G.A. although both have been largely satisfactory. Appendicectomy is more likely to produce wound sepsis than is gynaecological surgery, but before Mr Foster and his colleagues condemn the subcuticular suture they should make a trial of the unreactive material prolene, fixing the ends with beads and lead sinkers and removing the stitch after 5 or 6 days. The material is as important as the method. On

t testing the mean birth-weight of babies born to non-smokers significantly greater than the mean birth-weights of babies born to smokers, as follows: (A) p<0-001 (mean for smokers 3327 g, N=1528); (B) p<0.001 (mean for smokers 3305 g, N=748); and (C) p
later. 72% responded.’ This is an exceptionally narrow band within one social class and very homogeneous in regard to income and education. The results (see table) show that, in the whole series and within narrower age and gestation groups, there is a highly significant fall in mean birth-weight with smoking. There is a falling gradient with the amount smoked, which is seen in all except the smallest subgroups. These findings will be described in detail elsewhere, and we hope that they may convince those who still believe that the low birth-weight commonly found in babies of smokers is a social-class effect. Since Yerushalmy’s death, a lot more evidence on the effects of maternal smoking on the fetus has been published. Maternal smoking slows tal breathing movements and is associated with toxic constituents in cord blood.2 We would do better to develop new methods of persuading mothers not to smoke at any time in pregnancy than to reopen the question of the interference of smoking with fetal growth. We thank Mrs S. Moss for the

Department of Community Health, London School of Hygiene and Tropical Medicine, London WC1

Queen Charlotte’s Hospital, London W6

computation. EVA ALBERMAN PETER PHAROAH

GEOFFREY CHAMBERLAIN

LUNCHTIME GIN AND TONIC

Sm,—Some people say "my blood-alcohol is low" when they feel they need a drink, but it is interesting to read, in the paper by Dr O’Keefe and Professor Marks (June 18, p. 1286), 1. Pharoah, P.O. D., Alberman, E., Doyle, P., Chamberlain, G. Lancet, 1977,

i, 34. 2. Br. med.

J. 1976, ii, 189.

Birmingham Birmingham

and Midland B11 4HL

Hospital

for Women,

WILFRID MILLS

SiR,—Mr Foster and his colleagues conclude that subcuticular suturing cannot be recommended as a method of closure after appendicectomy. I do not feel that their data justify this conclusion. Firstly, Mr Foster and his colleagues compare different suture materials in the two closure techniques. Polyglycolic acid, unlike nylon, carries a high risk of tissue reaction and wound erythema when used as a subcuticular or even a subcutaneous suture. One plastic surgeon I know has stopped using it in facial surgery for this reason. Secondly, to close the skin with a sealing subcuticular suture after removing a gangrenous or perforated appendix seems contrary to elementary surgical principles: a higher infection-rate with the subcuticular suture in this situation cannot be held against the subcuticular technique itself. I have used subcuticular 4-0 nylon closures in many appendicectomies, but only if the appendix was not gangrenous or perforated. I am very pleased with the cosmetic results, as are most of my patients. Unlike Mr Foster and his colleagues I find subcuticular suturing a very desirable closure provided it is applied with judgment. General and Cardiovascular Surgery, P.S.K. Surgical Associates S.C. Elgin, Illinois 60120, U.S.A.

OLAF S. ANDERSEN

INTRAPERITONEAL POVIDONE IODINE

SIR,-When writing about povidone iodine’ it is very impordefine terms. A 10% solution of povidone iodine (’Betadine’) contains 1% available iodine, which means that 550 ml of such a solution, as used by Strife et al.1 would release 5500 tant to

intraperitoneal median lethal dose iodine in mice is 40-60 mg available

mg of available iodine. The

of

povidone

(L.D’50) iodine/kg body-weight2,1 (i.e., equivalent to giving a 70 kg man 2800-4200 mg of available iodine), In controlled studies of experimental peritonitis in mice and rats the therapeutically 1. Strife, C. F., Uhl, M., Morris, D., Fallon, G. Lancet, 1977, i, 2. Gilmore, O. J. A. M.S. thesis, University of London, 1976. 3. Gilmore, O. J. A.Ann. R. Coll. Surg. Eng. 1977, 59, 93.

1265.

38 effective dose of povidone iodine was found to be 6.0-7.5 mg available iodine/kg body-weight, almost ten times less than the L.D.50* Intraperitoneal povidone iodine in this dose significantly reduced the mortality of both mice and rats with Escherichia coli peritonitis.3 This therapeutically effective dose is equivalent to giving a 70 kg man 42-52 ml of 10% povidone iodine solution (i.e., over ten times less than that administered by Strife et al. to a 15-year-old child). Despite the amount of povidone iodine used in this case no abnormality was attributed specifically to the povidone iodine other than raised serum and urine iodine levels. The abnormal liver-function test (raised S.G.O.T.) was present preoperatively, and the haematuria and proteinuria were attributed to the high-dose antibiotic therapy. The case reported by Strife et al. seems to be a tribute to the safety of povidone iodine. St. Bartholomew’s Hospital, London EC1A 7BE

O. J. A. GILMORE

INTRAOSSEOUS FLUID ADMINISTRATION

SIR,-I was surprised that Dr Valdes’ could find so little in the literature about the administration of fluids by the intraosseous route. This is an old technique that has been well described in standard works in surgery in this country. I refer you to one such description.2 Department of Pædiatric Surgery, University of Liverpool, Alder Hey Children’s Hospital, Liverpool L12 2AP

R.

J. BRERETON

THE CONCEPT "A DISEASE"

concerned about usages of the names of disin medical discourse. Our concern is not with "disease" in the general sense of a "a morbid condition of the body... or some part, illness, sickness", but with "a particular kind of this with ... a name" (Concise Oxford English Dictionary, 1964). One of us has discussed the problems arising from lack of agreement among doctors about what they mean when they refer to a disease, and has suggested a definition for use in

SIR,-We

are

eases

medical discourse.33 We have made an experimental study of the opinions of doctors and of some other groups to find out to what extent their verbal usages are compatible with this or any other formal definition that may be devised. The groups studied include family doctors practising in Canada, British and Canadian academic physicians (internists), junior and senior medical students at McMaster University, Canadian university staff in non-medical faculties, and British (sixth form) and Canadian (grade 12) secondary-school students. The report of this study is being prepared for publication. However, we do not want to publish this report until others who share our interest have had the opportunity to extend the study to other groups of doctors and informed non-medical people, and possibly to offer alternative interpretations to ours. Obviously, once our study is published, particularly if, as we hope, it appears in a widely read journal, further studies among doctors may well be biased. Through your columns we are therefore inviting the participation of others who share our interest and who may be able to obtain further data. We invite inquiries from people who have access to groups of the following: non-medical persons of comparable educational background to doctors, both scientific and non-scientific; general medical practitioners; physicians (internists) in any specialty; surgeons; psychiatrists and psy-

biomedical scientists; and medical students. The inhave used consists of a list of 38 commonly used diagnostic terms familiar to lay as well as medical Englishspeaking people on both sides of the Atlantic. It is submitted in the form of a questionnaire to groups of 20-100, and each procedure takes about ten minutes. We would be especially pleased to hear from anybody who is fluently-not just medically-bilingual in English and another language, and who would be prepared to translate the terms into this language and apply the questionnaire to appropriate groups of people speaking it. Anyone who is interested in this project should write to E.J.M.C. describing the groups he proposes to study. When agreement on participation has been reached, the list of terms, the questionnaire sheet, and instructions for the conduct of the experiment will be sent. Although the analysis is not complex, Prof. Robin Roberts, of the department of epidemiology and biostatistics, McMaster University, has developed computer programs permitting examination of a number of hypotheses suggested by our findings. We will be pleased to analyse by these methods the data obtained by anyone who is willing to collaborate with us. The deadline for inquiries about participation is Aug. 31, 1977, and for sending in results, Dec. 31, 1977. Participants will be sent the analysis of their own findings as soon as possible after this date. Those who are able to study groups in languages other than English are urged to write soon, so that their translations of the terms may be made available to others wishing to carry out the study in that language. We plan to complete the paper describing our results before examining results from other participants. We hope subsequently to prepare another paper based on the data from other centres and comparisons between these and ours. We shall not publish the results of all individual studies. However, the procedures detailed above will make the results of each study available to the person who performed it for publication separately, possibly as a challenge to our findings and interpretation in correspondence columns.

chologists ;

strument we

Department of Medicine,

J. M. CAMPBELL J. G. SCADDING* E.

McMaster University, Hamilton, Ontario, Canada *Present address: S Astor Close,

Kingston Hill, Kingstdn

Valdes, M. M. Lancet, 1977, i,1235. Bailey, H. in Bailey and Love’s A Short Practice of Surgery; p. 109. London,

3.

Scadding, J.

1962. G. Lancet,

1967, ii, 877.

Thames, Surrey.

THE ABHORRENCE OF STILLBIRTH

S!R,—Your editorial’ focused on a very important aspect of stillbirth. Insufficient attention is paid to the need for subsequent genetic counselling, and although the stillbirth is statutorily notifiable the importance of both post-mortem examination and X-ray cannot be overemphasised. These two examinations are complementary if the cause of the stillbirth is to be established. About 5% of stillbirths have chromosome abnormalities. Possibly the relative lack of medical interest in establishing the cause of death and, therefore, the inability to give adequate genetic counselling may simply be a reflection of the attitude Bourne2 found in 1968-i.e., doctors are compulsively reluctant to know, notice, or remember anything about mothers whose pregnancies end in stillbirths. If doctors and allied professionals are to fulfil their roles they must attempt to prevent later psychological disability and also offer genetic counselling for possible future pregnancy. X-Ray Department, Hospital for Sick Children,

I. GORDON

London WC1 1. 2.

upon

1. Lancet, 1977,i,1188. Bourne, S.JlR. Coll. gen. Practit.

2.

1968, 16, 103.