- Email: [email protected]
MEDICAL CONTROL OVER LABOUR
1242 the management of these cases. For example, the doses of the. drug used were not mentioned and it is perhaps noteworthy that " one patient had been in the medical ward 14 days on chloramphenicol before perforation". It has been our practice to give large doses of intravenous chloramphenicol preoperatively, continue the high doses during and after operation, and then reduce the dose as the patient improves over the first few postoperative days; for example, 1 g. of chloramphenicol is given at once intravenously, followed by 500 mg. 6-hourly intravenously until the patient improves, when the dose is reduced to 250 mg. 6-hourly orally when the patient Vitamin-B complex is given intrais able to take by mouth. venously during the critical stage and is changed to an oral preparation when the patient takes by mouth. Intravenous fluids and gastric suction are started urgently and, when indicated, blood is transfused. In my experience, the patient usually rallies on the above regimen, and it can almost be said that the outcome of surgery depends on the vigour with which these resuscitative
applied. Operation Simple closure of the perforation and drainage of the peritoneal cavity have consistently and predictably given good resdlts.
measures are
The
This is not to claim 100% success but to state my considered opinion that small-bowel resection or other form of radical operation as an alternative to simple closure in these critically ill patients borders on the heroic. Where stitches do not hold, a patch of greater omentum has proved useful.
Fifty patients in 14 years, managed " by many different surgeons", are hardly enough on which to base a treatment policy. This is where the experience of others, particularly in this part of the world, would be of value. Department of Surgery, General Hospital, Oron, South Eastern State,
A. A. OTU.*
Nigeria.
ELECTIVE INDUCTION OF LABOUR
SIR,-The correspondence columns of your journal
are a
of great interest to your readers. One week we are treated to a particular point of view and the next week to the contrary. We assess contributions and pay attention to the experience of the departments whence they come and to the reputations of their authors. The letter from the chairman of the Patients Association (May 10, p. 1088) makes it clear that this organisation is against the elective induction of labour, but the letter is written with a degree of scholarship and understanding which makes it plain that it was prepared by a doctor with an extensive knowledge of the literature. I have no doubt this doctor is a member of the Patients Association, but we cannot value the contribution as effectively as we should like if we do not know the name of the doctor and his or her experience in obstetrics. Clearly the Patients Association has every right to partake in a medical debate, but it would help obstetricians more if we knew why that Association was opposed to the induction of labour. If they can tell us what the patients would like, we would try to comply. Strangely enough, the obstetricians and the Patients Association probably have the same common interestthe wellbeing of the patient. source
Royal Cornwall Hospital (Treliske), Truro, Cornwall.
** * We showed this letter reply follows.-ED. L.
B. S. Cox. to
Mrs Robinson, whose
to be criticising his colleagues whilst sheltering behind the skirts of the chairman of the Patients Association is a figment of his imagination. You do not need to be a doctor to acquire an " extensive " knowledge of the literature. All you need is a good library and a curiosity acquired by reading over 800 letters from women about induced births. So many of those who could compare an induced birth with other births asked whether the doctors really knew what they were doing, that I couldn’t resist trying to find out. It’s as simple as that. The already well-documented risks seem to suggest a policy of caution on elective induction. But we are also concerned about the risks which we suspect may exist but which have not yet been investigated-for example, the possible effects on mental health and mother/child relationships. Measured in terms of total family morbidity, the picture may be less satisfactory than many dedicated and caring obstetricians have yet realised. Patients Association, 335 Gray’s Inn Road, London WC1X 8PX. JEAN ROBINSON.
thought
MEDICAL CONTROL OVER LABOUR
SIR,-Your editorial on induction of labour (Nov. 16, p. 1183) was a timely review of the procedure’s safety, but you treated other relevant issues cursorily. Modern obstetric practices are not humanity’s only attempts to modify labour. Every known culture has had rituals about the powerful and important events of childbirth. While it has been claimed that hunting and gathering cultures, the societal form in which humanity evolved, rarely disturbed " natural " processes, anthropologists report that some such groups regularly sought to change labour’s course. For example, the Mullu Kurumba and the Malla Ulladan, contemporary tribes in India, manually lubricate and vigorously dilate the vagina .2 The Chagga of Africa perform episiotomies. The Lepcha of Asia and the Siriono of South America stimulate the nipples during labour, a procedure known to increase oxytocin release. Many cultures use herbs, some containing oxytocin-like compounds, to speed delivery.3 Contemporary Western culture emphasises control and domination of physiological processes. With the proclaimed purpose of improving health, obstetrics offers an everincreasing variety of techniques for modifying the onset, duration, pace, and termination of labour. Some women share this cultural enthusiasm for control. There are those who are relieved that management of a potentially frightening and overwhelming bodily process can be delegated to doctors. Others in the so-called " natural childbirth movement, similarly concerned with control, attempt personal mastery of labour and delivery by physical and "
psychological preparation. This cultural bias towards control is manifest in your editorial position-any medical control over labour would be permissible if it were safe. Characteristically, only physical dangers are considered; psychological consequences are ignored. Without documentation, physicians have claimed that women are pleased with doctors’ intervention in childbirth .4,5 This interpretation of mothers’ reactions is certainly challenged in the popular literature.’,’,’ A woman’s emotional experience of childbirth may be as important for her health and that of her child as the
-
"
"
is scholarship the I that use someone flattering, although suggestion might else’s work without acknowledgment is not. I can reassure him, however. The wee, cowering, timorous obstetrician
SIR,-Mr Cox’s reference
to
my
1. Birth Book. Felton, California, 1972. 2. Misra, R. Unpublished. 3. Mead, M., Newton, N. in Childbearing: Its Social and Psychological Aspects (edited by S. A. Richardson and A. F. Guttmacher); p. 217. Baltimore, 1967. 4. Tacchi, D. Lancet, 1971, ii, 1134.
5. Newsweek, July 20, 1970, p. 85. * Present address: Department of Bacteriology and Immunology, University of Glasgow, Western Infirmary, Glasgow G11 6NT.
6. Robinson, J. Times, Aug. 12, 1974. 7. Ladies Home Journal, August, 1970, p. 66.
1243
physical factors involved. The medical profession might take time from studying physical effects and techniques of induction to evaluate the broader consequences of increasing medical control over physiology. Division of
Geographic Medicine,
Department of Medicine, and Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio 44106, U.S.A.
BETSY LOZOFF.
Anthropological Survey of India, Mysore 2, India.
RAJALAKSHMI
MISRA.
GENETIC DISORDERS IN GYPSIES
SIR,—In response to the inquiry by Dr Harper and Mr Williams (May 3, p. 1041) about rare recessive disorders in Gypsy populations in Europe, I should like to record the occurrence of citrullinsemia in an inbred Gypsy kindred originating from Hungary and Poland, now residing in Northern Germany. After the birth of the first affected offspring of a consanguineous couple (inbreeding coefficient of 009375), I have monitored the next pregnancy. The prenatal diagnosis, based on a normal 14C-citrulline incorporation of cultured amniotic-fluid cells in comparison to known mutant cells, has just been confirmed postnatally No other recessive disorder has been observed in this kindred. Institut für Humangenetik, Universität Hamburg, Martinistrasse 52, 2 Hamburg 20, West Germany.
E. PASSARGE.
LITHIUM, CALCIUM, AND PHOSPHATE SIR,—Dr Crammer (Jan 25, p. 215) reported reduced urinary excretion of calcium in patients during lithium We have observed similar changes in two treatment. with lithium. The urinary excretion of treated patients calcium and phosphate was measured before and after the start of
lithium
therapy.
1 and 2 show decreased excretion of calcium and phosphate in the lithium treatment periods, and the decrease appeared immediately after lithium was first given. During the whole investigation the patients were on a diet containing about 30 mmol calcium and 40 mmol phos-
Figs.
Fig. 2-24-hour urinary phosphate excretion
in two patients before and after treatment with lithium.
phorus per day, and this standardisation should exclude the possibility that the changes were due to changes in diet. In a crossover study of 12 Meniere patients, who were on and off lithium treatment for two periods of six months each, 24-hour urine was collected once in each period. The excretion of calcium in the lithium-free period was 7.36±2.29 mmol per 24 hours and during lithium treatment 4800-98 mmol per 24 hours (P<0.001). In a study of calcium and phosphate metabolism, urinary excretion alone gives far from a true picture of the total balance of these two elements, since most of the excretion of calcium, and about 50% of the excretion of phosphate, takes place via the fseces. A thorough investigation of lithium effects on calcium and phosphate metabolism must therefore encompass both urinary and fsecal excretion. Such studies are now in progress in our metabolic ward, and preliminary results indicate that lithium induces retention of both calcium and phosphate. These long-term effects of lithium are of importance in relation, among other things, to theories of manicmelancholic disorders focusing on electrolyte disturbances.l NIELS BJØRUM IB HORNUM ERLING T. MELLERUP PER K. PLENGE OLE J. RAFAELSEN.
Psychochemistry Institute, Rigshospitalet, 9 Blegdamsvej, DK-2100 Copenhagen, Denmark.
POLYGLYCOLIC-ACID SUTURES AND HYPERTROPHIC SCARS
SIR,—Iread with interest the paper by Dr Clough and Mr Alexander-Williams (Jan. 25, p. 194) and the subsequent correspondence on the use of polyglycolic-acid (P.G.A.) sutures for skin closures. Subcuticular P.G.A. sutures have been used on this unit for the past five years for all skin closures, including acute surgery in the presence of sepsis. It has been increasingly obvious that a proportion of wounds proceed to hypertrophic scar formation. In our experience, however, this phenomenon has been confined to those vertical abdominal incisions closed with 00 P.G.A. Transverse abdominal incisions are closed with 000 P.G.A. and thyroidectomy . incisions and incisions in children with 0000 P.G.A. Many of these, particularly the thyroid cases, are followed up for Fig. 1-24-hour urinary calcium excretion in two patients before and after treatment with lithium.
1.
Rafaelsen, O. J., Mellerup, Amst. 1973, 76, 523.
E.
T. Psychiat. Neurol. Neurochir,
applied. Operation Simple closure of the perforation and drainage of the peritoneal cavity have consistently and predictably given good resdlts.
measures are
The
This is not to claim 100% success but to state my considered opinion that small-bowel resection or other form of radical operation as an alternative to simple closure in these critically ill patients borders on the heroic. Where stitches do not hold, a patch of greater omentum has proved useful.
Fifty patients in 14 years, managed " by many different surgeons", are hardly enough on which to base a treatment policy. This is where the experience of others, particularly in this part of the world, would be of value. Department of Surgery, General Hospital, Oron, South Eastern State,
A. A. OTU.*
Nigeria.
ELECTIVE INDUCTION OF LABOUR
SIR,-The correspondence columns of your journal
are a
of great interest to your readers. One week we are treated to a particular point of view and the next week to the contrary. We assess contributions and pay attention to the experience of the departments whence they come and to the reputations of their authors. The letter from the chairman of the Patients Association (May 10, p. 1088) makes it clear that this organisation is against the elective induction of labour, but the letter is written with a degree of scholarship and understanding which makes it plain that it was prepared by a doctor with an extensive knowledge of the literature. I have no doubt this doctor is a member of the Patients Association, but we cannot value the contribution as effectively as we should like if we do not know the name of the doctor and his or her experience in obstetrics. Clearly the Patients Association has every right to partake in a medical debate, but it would help obstetricians more if we knew why that Association was opposed to the induction of labour. If they can tell us what the patients would like, we would try to comply. Strangely enough, the obstetricians and the Patients Association probably have the same common interestthe wellbeing of the patient. source
Royal Cornwall Hospital (Treliske), Truro, Cornwall.
** * We showed this letter reply follows.-ED. L.
B. S. Cox. to
Mrs Robinson, whose
to be criticising his colleagues whilst sheltering behind the skirts of the chairman of the Patients Association is a figment of his imagination. You do not need to be a doctor to acquire an " extensive " knowledge of the literature. All you need is a good library and a curiosity acquired by reading over 800 letters from women about induced births. So many of those who could compare an induced birth with other births asked whether the doctors really knew what they were doing, that I couldn’t resist trying to find out. It’s as simple as that. The already well-documented risks seem to suggest a policy of caution on elective induction. But we are also concerned about the risks which we suspect may exist but which have not yet been investigated-for example, the possible effects on mental health and mother/child relationships. Measured in terms of total family morbidity, the picture may be less satisfactory than many dedicated and caring obstetricians have yet realised. Patients Association, 335 Gray’s Inn Road, London WC1X 8PX. JEAN ROBINSON.
thought
MEDICAL CONTROL OVER LABOUR
SIR,-Your editorial on induction of labour (Nov. 16, p. 1183) was a timely review of the procedure’s safety, but you treated other relevant issues cursorily. Modern obstetric practices are not humanity’s only attempts to modify labour. Every known culture has had rituals about the powerful and important events of childbirth. While it has been claimed that hunting and gathering cultures, the societal form in which humanity evolved, rarely disturbed " natural " processes, anthropologists report that some such groups regularly sought to change labour’s course. For example, the Mullu Kurumba and the Malla Ulladan, contemporary tribes in India, manually lubricate and vigorously dilate the vagina .2 The Chagga of Africa perform episiotomies. The Lepcha of Asia and the Siriono of South America stimulate the nipples during labour, a procedure known to increase oxytocin release. Many cultures use herbs, some containing oxytocin-like compounds, to speed delivery.3 Contemporary Western culture emphasises control and domination of physiological processes. With the proclaimed purpose of improving health, obstetrics offers an everincreasing variety of techniques for modifying the onset, duration, pace, and termination of labour. Some women share this cultural enthusiasm for control. There are those who are relieved that management of a potentially frightening and overwhelming bodily process can be delegated to doctors. Others in the so-called " natural childbirth movement, similarly concerned with control, attempt personal mastery of labour and delivery by physical and "
psychological preparation. This cultural bias towards control is manifest in your editorial position-any medical control over labour would be permissible if it were safe. Characteristically, only physical dangers are considered; psychological consequences are ignored. Without documentation, physicians have claimed that women are pleased with doctors’ intervention in childbirth .4,5 This interpretation of mothers’ reactions is certainly challenged in the popular literature.’,’,’ A woman’s emotional experience of childbirth may be as important for her health and that of her child as the
-
"
"
is scholarship the I that use someone flattering, although suggestion might else’s work without acknowledgment is not. I can reassure him, however. The wee, cowering, timorous obstetrician
SIR,-Mr Cox’s reference
to
my
1. Birth Book. Felton, California, 1972. 2. Misra, R. Unpublished. 3. Mead, M., Newton, N. in Childbearing: Its Social and Psychological Aspects (edited by S. A. Richardson and A. F. Guttmacher); p. 217. Baltimore, 1967. 4. Tacchi, D. Lancet, 1971, ii, 1134.
5. Newsweek, July 20, 1970, p. 85. * Present address: Department of Bacteriology and Immunology, University of Glasgow, Western Infirmary, Glasgow G11 6NT.
6. Robinson, J. Times, Aug. 12, 1974. 7. Ladies Home Journal, August, 1970, p. 66.
1243
physical factors involved. The medical profession might take time from studying physical effects and techniques of induction to evaluate the broader consequences of increasing medical control over physiology. Division of
Geographic Medicine,
Department of Medicine, and Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio 44106, U.S.A.
BETSY LOZOFF.
Anthropological Survey of India, Mysore 2, India.
RAJALAKSHMI
MISRA.
GENETIC DISORDERS IN GYPSIES
SIR,—In response to the inquiry by Dr Harper and Mr Williams (May 3, p. 1041) about rare recessive disorders in Gypsy populations in Europe, I should like to record the occurrence of citrullinsemia in an inbred Gypsy kindred originating from Hungary and Poland, now residing in Northern Germany. After the birth of the first affected offspring of a consanguineous couple (inbreeding coefficient of 009375), I have monitored the next pregnancy. The prenatal diagnosis, based on a normal 14C-citrulline incorporation of cultured amniotic-fluid cells in comparison to known mutant cells, has just been confirmed postnatally No other recessive disorder has been observed in this kindred. Institut für Humangenetik, Universität Hamburg, Martinistrasse 52, 2 Hamburg 20, West Germany.
E. PASSARGE.
LITHIUM, CALCIUM, AND PHOSPHATE SIR,—Dr Crammer (Jan 25, p. 215) reported reduced urinary excretion of calcium in patients during lithium We have observed similar changes in two treatment. with lithium. The urinary excretion of treated patients calcium and phosphate was measured before and after the start of
lithium
therapy.
1 and 2 show decreased excretion of calcium and phosphate in the lithium treatment periods, and the decrease appeared immediately after lithium was first given. During the whole investigation the patients were on a diet containing about 30 mmol calcium and 40 mmol phos-
Figs.
Fig. 2-24-hour urinary phosphate excretion
in two patients before and after treatment with lithium.
phorus per day, and this standardisation should exclude the possibility that the changes were due to changes in diet. In a crossover study of 12 Meniere patients, who were on and off lithium treatment for two periods of six months each, 24-hour urine was collected once in each period. The excretion of calcium in the lithium-free period was 7.36±2.29 mmol per 24 hours and during lithium treatment 4800-98 mmol per 24 hours (P<0.001). In a study of calcium and phosphate metabolism, urinary excretion alone gives far from a true picture of the total balance of these two elements, since most of the excretion of calcium, and about 50% of the excretion of phosphate, takes place via the fseces. A thorough investigation of lithium effects on calcium and phosphate metabolism must therefore encompass both urinary and fsecal excretion. Such studies are now in progress in our metabolic ward, and preliminary results indicate that lithium induces retention of both calcium and phosphate. These long-term effects of lithium are of importance in relation, among other things, to theories of manicmelancholic disorders focusing on electrolyte disturbances.l NIELS BJØRUM IB HORNUM ERLING T. MELLERUP PER K. PLENGE OLE J. RAFAELSEN.
Psychochemistry Institute, Rigshospitalet, 9 Blegdamsvej, DK-2100 Copenhagen, Denmark.
POLYGLYCOLIC-ACID SUTURES AND HYPERTROPHIC SCARS
SIR,—Iread with interest the paper by Dr Clough and Mr Alexander-Williams (Jan. 25, p. 194) and the subsequent correspondence on the use of polyglycolic-acid (P.G.A.) sutures for skin closures. Subcuticular P.G.A. sutures have been used on this unit for the past five years for all skin closures, including acute surgery in the presence of sepsis. It has been increasingly obvious that a proportion of wounds proceed to hypertrophic scar formation. In our experience, however, this phenomenon has been confined to those vertical abdominal incisions closed with 00 P.G.A. Transverse abdominal incisions are closed with 000 P.G.A. and thyroidectomy . incisions and incisions in children with 0000 P.G.A. Many of these, particularly the thyroid cases, are followed up for Fig. 1-24-hour urinary calcium excretion in two patients before and after treatment with lithium.
1.
Rafaelsen, O. J., Mellerup, Amst. 1973, 76, 523.
E.
T. Psychiat. Neurol. Neurochir,