- Email: [email protected]
PARENTS ANONYMOUS
878
preliminary results indicate a possible use for the H.A. only as a test for A.F.p.-producing tumours but also for prospective screening for neural-tube defects. Serum-A.F.p. levels above a critical level should be tested further, either by the H.A. test or by quantitative radioimmunoassay. By increasing the dilution of elevated serum samples a semiquantitative estimation of the A.F.P. level could be made by the H.A. test. These
test not
These results could indicate whether an amniotic-fluid A.F.P. estimation should be carried out. Therefore the H.A. test may be a simple alternative test in prospective screening-trials instead of the more complicated radioimmunoassays. Department of Clinical Chemistry A, Rigshospitalet, University Hospital, DK-2100 Copenhagen, Denmark.
B.
NØRGAARD-PEDERSEN
LATE COMPLICATIONS OF STERILISATION BY
LAPAROSCOPY
SIR,-We were interested in the survey by Dr Neil and his colleagues (Oct. 11, p. 699). We had performed a similar study on a London population which is being published in full elsewhere. In several aspects both studies produce similar results, but we come to slightly different conclusions. Since it is difficult to estimate the amount of menstrual loss, in our questionnaire survey we asked the number of days the patient had heavy bleeding, days of total menstrual loss, and days of cycle for
we
felt that it
was
easier for her
to measure
numbers of
days rather than quantity of loss. Of 200 women who had laparoscopy sterilisation, two years later 34% reported longer periods and 32% reported more days of heavy menstruation whilst a fifth had a shorter cycle or less days of heavy menstruation. There was little difference between these patients and a group of women having laparotomy sterilisation. However, we found differing results from the Southampton workers when we considered the effects of previous contraception (see accompanying table). COMPARISON OF MENSTRUATION IN WOMEN HAVING LAPAROSCOPY STERILISATION ACCORDING TO METHOD OF CONTRACEPTION BFFORF OPERATION
(n=187)
menorrhoea in the 126 patients who were not using oral contraception before surgery. Retrospective studies on symptoms are always difficult to evaluate, but if more facets are looked at, the effects found may not be tied to the original cause postulated but to some coincidental event which has become apparent in the course of ’
the survey. Queen Charlotte’s Maternity Hospital, Goldhawk Road, London, W6
GEOFFREY CHAMBERLAIN JOHN FOULKES
CONGENITAL ABNORMALITIES ASSOCIATED WITH MATERNAL CLOMIPHENE INGESTION SIR,-There have been several reports of neural-tube defects in children of mothers treated with clomiphene immediately prior to or at the time of conception.’-’ Other congenital anomalies have also been noted.5 However, a causal relationship has not been established. We have seen a girl with multiple congenital abnormalities born 39t weeks after her mother’s last menstrual
period. The patient appeared to be fully mature at birth. There was distal syndactyly of the left 2nd, 3rd, and 4th fingers and a tissue band that bridged their flexor surfaces, a mild degree of proximal skin syndactyly of these fingers, and amputation of the distal part of the 5th finger. The right thenar crease was indistinct. There was distinct thoraco-lumbar scoliosis. The muscle bulk was decreased in the lower limbs, with the left side smaller than the right and held in internal rotation. Both hips and the left knee were subluxated, and the feet were clubbed. There was impaired sensation, with response only to deep pain, and absent reflexes in the lower limbs. Electromyography showed widespread denervation in all the muscles of the lower limbs except the right quadriceps. There was bulging of the lower left quadrant resulting from partial absence of the abdominal muscles. The patient had telecanthus and a broad nasal bridge, The left kidney was not displayed on intravenous urography. This was the 27-year-old mother’s first pregnancy. She had taken clomiphene at the recommended periods for two months (February and March, 1974). She did not menstruate in March, and had her last period in April, 1974. For 4 months (May to September, 1974), she had nausea and vomiting, which were not alleviated by dimenhydrinate. There was no vaginal bleeding or fluid loss.
This pattern of malformation has been reported many no single specific cause has been implicated. We are not aware of any evidence that clomiphene causes such defects, but in view of the widespread use of this drug I wonder if other physicians have seen similar anomalies in the offspring of women treated with clomiphene.
times, but
Department of Medical Genetics, Montreal Children’s Hospital, Montreal, Canada.
PAIGE BERMAN
PARENTS ANONYMOUS
having laparotomy sterilisation by their previous contraceptive methods showed that many more of the oral contraceptive group had both longer menstruation and more days of heavy bleeding after the operation than did those who had no contraception. Both these differences were highly significant (P<0-001). Although smaller in number, the group previously using the intrauterine device had a reduction in the length and number of days of heavy menstruation which was significant at the level p<0.05. We wondered if these effects might have followed the withdrawal of hormones or the A breakdown of
women
removal of the intrauterine device and if it was these coincident events which caused the alteration of menstrual loss. Like the Southampton workers, we found an increase in dysmenorrhoea from 39% to 49% in the group who had laparoscopy sterilisation, but this shift was almost entirely composed.of women who had been on oral contraceptive before. If this group was excluded, there was no increase in dys-
SIR,—The article by Dr Lynch on ill-health and child abuse (Aug. 16, p. 317), and the subsequent letter from Dr Howells (Sept. 6, p. 454), have prompted me to write about the Parents
Anonymous organisation which has been set up in North America. It is a self-help organisation run by and for parents who have abused, or feel in danger of abusing, their children. There are now about 55 chapters, each of which has the help of a professional sponsor. Members volunteer to answer telephone calls from the community, and frequent meetings are held to discuss problems. A talk with someone who has experi1. Dyson, J. L., Kohler, H. G. Lancet, 1973, i, 1256. 2. Sandler, B. ibid. 1973, ii, 379. 3. Barrett, C., Hakim, C. ibid. p. 916. 4. Field, B., Kerr, C. ibid. 1974, ii, 1511. 5. W. M. Merrell Co. Production Information Clomid. Cincinnati, Ohio, 1973.
879 enced a similar problem can often reassure and calm a parent in crisis. This help is immediately available and non-threatening (and therefore, perhaps, more readily sought than professional help by a distraught parent), and parents can subsequently be referred with the help of P.A. to the appropriate agency. Parents participating in the scheme say that continuing contact with P.A. helps them to understand their problems and thus to cope with their family situation. 276 Drewry Avenue,
LINDA TU
Willowdale, Ontario, Canada M2M 1E5.
SURVIVAL AFTER DROWNING
SIR,—The important claim of Dr Wind (Oct. 4,
p.
656) con-
cerning recovery of cortical function in a child who survived for 14 hours after drowning in cold water is not, in our view, supported by convincing evidence. The E.E.G. was "virtually isoelectric" at 5 hours after intubation, and the evidence of returning cortical function was believed to be the seizures and the mother’s claim that the infant responded to her. Seizures can occur without a normally functioning cerebral
Parliament
Abortion THE Government’s plans for tightening up on abuses of the abortion law were announced in the House of Commons on Oct. 21. In her statement Mrs BARBARA CASTLE, Secretary of State for Social Services, said that the Government accepted in principle all the recommendations made by the Select Committee which had been considering Mr James White’s Abortion (Amendment) Bill; many of those recommendations had been put forward originally by the Lane Committee on the Working of the Abortion Act. Action had already been taken with the object of requiring private nursing-homes which concentrated on abortion to give an assurance concerning the total fees charged to patients. Assurances had also been sought from all approved nursing-homes about financial arrangements with referral agencies. Only those private nursing-homes with adequate facilities would be authorised to carry out terminations of pregnancy after the 20th week. Nursing-homes had also been asked for information on the number of foreign patients treated during the 18 months to June 30, 1975, and similar information would be sought from all approved nursing-homes at quarterly intervals in future. A review was being made of the arrangements which nursing-homes made for the reception, counselling, and after-care of foreign patients, and changes would be required where necessary. As recommended by the Select Committee, the Health Ministers would be issuing a list of approved referral bureaux, and would refuse to approve clinics which accepted patients from unlisted bureaux; application forms had been issued to bureaux and agencies. A draft paper giving guidance on counselling would be circulated for consultation to bodies representing the medical, nursing, and social-work professions. The Select Committee had recommended that in the N.H.S. terminations after the 20th week of pregnancy should be carried out only in hospitals possessing appropriate facilities, including resuscitation equipment, and this recommendation had been accepted. A circular had been issued to health authorities asking for the adoption of the code of practice of the Peel Advisory Group on the Use of Fetuses and Fetal Material, and a similar request would be put to the private nursing-homes. Some of the other recommendations of the Select Committee would require amendment of the Abortion Regulations of 1968, Mrs Castle went on to say, and the Department of
cortex, and the return of brainstem functions is well recognised in patients with neocortical death’ who may survive for long periods in a vegetative state.2 As Jennett and Plum2 pointed out, reflex responses at spinal or brainstem level can be interpreted by "a hopeful family" as "purposeful or voluntary". In contrast to the cases previously reported3in which rectal temperature was 25°C, the degree of hypothermia (35OC) at the time of hypoxia in this case could not have afforded significant protection for the brain. The available evidence indicates that a child’s brain and heart could be deprived of oxygen for half-an-hour and regain their function only if there had been considerable hypothermia. Section of Neurological Sciences, The London Hospital, London E1 1BB, and Medical Research Council Laboratories,
PAMELA F. PRIOR
Carshalton, Surrey.
J. B. BRIERLEY
1.
Brierley, J. B., Adams, J. H., Graham, D. I., Simpson, J. A. Lancet, 1971, ii, 560. 2. Jennett, B., Plum, F. ibid. 1972, i, 734. 3. Siebke, H., Breivik, H., Rød, T., Lind, B. ibid. 1975, i, 1275. 4. Kvittingen, T. D., Naess, A. Br. med. J. 1963, i, 1315.
Health would be considering the whole question of the procedure for the certification and notification of abortions. It had already been decided, however, that the Regulations would be amended to allow the disclosure to the General Medical Council, on request, of information taken from the notification to the chief medical officers of the Health Departments. It had further been accepted that the Regulations would be amended to ensure that doctors who certified that the conditions of the Abortion Act were met in a particular case should always examine the patient. Guidance had been issued to health authorities on day-care systems, and the Department was hoping to authorise day-care services in some private clinics with a record of high standards. The most important preventive action which the Government had taken was to introduce as part of the N.H.S. a comprehensive family-planning service, which started to function fully this summer. Mrs Castle concluded her statement by explaining that under the procedure whereby Mr White’s Bill had been committed to a Select Committee, the Bill and the Committee would lapse at the end of the present Parliamentary session. The Government felt that Parliament should be given an opportunity to decide whether the Select Committee should be re-established, as the Committee itself had requested, and a motion would be tabled early in the next session. In answer to a question suggesting that hospitals had been directed not to employ obstetricians unless they were willing to carry out abortions, Mrs Castle said that there had been a misunderstanding on this point. Doctors with a conscientious objection to abortion were not being excluded from working in the N.H.S.; however, it had to be accepted that the N.H.S. was under an obligation to provide an abortion service as laid down by Parliament, and if the service was to continue it was essential to ensure that doctors were available to carry out abortions. Of 70 appointments in obstetrics and gynaecology and in anaesthetics made since March 1 this year, there had been only 9 where the need for a willingness to carry out abortions had been specified. Mrs RENEE SHORT asked what exactly the Department had in mind for the women who presented themselves after 20 weeks for a termination of pregnancy; if the Secretary of State intended that they should all be dealt with in N.H.S. hospitals, then a guarantee should be given now that facilities would be made available in every region of the country. Mrs Castle agreed that there were areas of the N.H.S. where facilities were not available for abortions as provided for by legislation; this was connected with the question of doctors and conscientious objections. The Department would do the best it could in difficult circumstances to provide a uniform service.
preliminary results indicate a possible use for the H.A. only as a test for A.F.p.-producing tumours but also for prospective screening for neural-tube defects. Serum-A.F.p. levels above a critical level should be tested further, either by the H.A. test or by quantitative radioimmunoassay. By increasing the dilution of elevated serum samples a semiquantitative estimation of the A.F.P. level could be made by the H.A. test. These
test not
These results could indicate whether an amniotic-fluid A.F.P. estimation should be carried out. Therefore the H.A. test may be a simple alternative test in prospective screening-trials instead of the more complicated radioimmunoassays. Department of Clinical Chemistry A, Rigshospitalet, University Hospital, DK-2100 Copenhagen, Denmark.
B.
NØRGAARD-PEDERSEN
LATE COMPLICATIONS OF STERILISATION BY
LAPAROSCOPY
SIR,-We were interested in the survey by Dr Neil and his colleagues (Oct. 11, p. 699). We had performed a similar study on a London population which is being published in full elsewhere. In several aspects both studies produce similar results, but we come to slightly different conclusions. Since it is difficult to estimate the amount of menstrual loss, in our questionnaire survey we asked the number of days the patient had heavy bleeding, days of total menstrual loss, and days of cycle for
we
felt that it
was
easier for her
to measure
numbers of
days rather than quantity of loss. Of 200 women who had laparoscopy sterilisation, two years later 34% reported longer periods and 32% reported more days of heavy menstruation whilst a fifth had a shorter cycle or less days of heavy menstruation. There was little difference between these patients and a group of women having laparotomy sterilisation. However, we found differing results from the Southampton workers when we considered the effects of previous contraception (see accompanying table). COMPARISON OF MENSTRUATION IN WOMEN HAVING LAPAROSCOPY STERILISATION ACCORDING TO METHOD OF CONTRACEPTION BFFORF OPERATION
(n=187)
menorrhoea in the 126 patients who were not using oral contraception before surgery. Retrospective studies on symptoms are always difficult to evaluate, but if more facets are looked at, the effects found may not be tied to the original cause postulated but to some coincidental event which has become apparent in the course of ’
the survey. Queen Charlotte’s Maternity Hospital, Goldhawk Road, London, W6
GEOFFREY CHAMBERLAIN JOHN FOULKES
CONGENITAL ABNORMALITIES ASSOCIATED WITH MATERNAL CLOMIPHENE INGESTION SIR,-There have been several reports of neural-tube defects in children of mothers treated with clomiphene immediately prior to or at the time of conception.’-’ Other congenital anomalies have also been noted.5 However, a causal relationship has not been established. We have seen a girl with multiple congenital abnormalities born 39t weeks after her mother’s last menstrual
period. The patient appeared to be fully mature at birth. There was distal syndactyly of the left 2nd, 3rd, and 4th fingers and a tissue band that bridged their flexor surfaces, a mild degree of proximal skin syndactyly of these fingers, and amputation of the distal part of the 5th finger. The right thenar crease was indistinct. There was distinct thoraco-lumbar scoliosis. The muscle bulk was decreased in the lower limbs, with the left side smaller than the right and held in internal rotation. Both hips and the left knee were subluxated, and the feet were clubbed. There was impaired sensation, with response only to deep pain, and absent reflexes in the lower limbs. Electromyography showed widespread denervation in all the muscles of the lower limbs except the right quadriceps. There was bulging of the lower left quadrant resulting from partial absence of the abdominal muscles. The patient had telecanthus and a broad nasal bridge, The left kidney was not displayed on intravenous urography. This was the 27-year-old mother’s first pregnancy. She had taken clomiphene at the recommended periods for two months (February and March, 1974). She did not menstruate in March, and had her last period in April, 1974. For 4 months (May to September, 1974), she had nausea and vomiting, which were not alleviated by dimenhydrinate. There was no vaginal bleeding or fluid loss.
This pattern of malformation has been reported many no single specific cause has been implicated. We are not aware of any evidence that clomiphene causes such defects, but in view of the widespread use of this drug I wonder if other physicians have seen similar anomalies in the offspring of women treated with clomiphene.
times, but
Department of Medical Genetics, Montreal Children’s Hospital, Montreal, Canada.
PAIGE BERMAN
PARENTS ANONYMOUS
having laparotomy sterilisation by their previous contraceptive methods showed that many more of the oral contraceptive group had both longer menstruation and more days of heavy bleeding after the operation than did those who had no contraception. Both these differences were highly significant (P<0-001). Although smaller in number, the group previously using the intrauterine device had a reduction in the length and number of days of heavy menstruation which was significant at the level p<0.05. We wondered if these effects might have followed the withdrawal of hormones or the A breakdown of
women
removal of the intrauterine device and if it was these coincident events which caused the alteration of menstrual loss. Like the Southampton workers, we found an increase in dysmenorrhoea from 39% to 49% in the group who had laparoscopy sterilisation, but this shift was almost entirely composed.of women who had been on oral contraceptive before. If this group was excluded, there was no increase in dys-
SIR,—The article by Dr Lynch on ill-health and child abuse (Aug. 16, p. 317), and the subsequent letter from Dr Howells (Sept. 6, p. 454), have prompted me to write about the Parents
Anonymous organisation which has been set up in North America. It is a self-help organisation run by and for parents who have abused, or feel in danger of abusing, their children. There are now about 55 chapters, each of which has the help of a professional sponsor. Members volunteer to answer telephone calls from the community, and frequent meetings are held to discuss problems. A talk with someone who has experi1. Dyson, J. L., Kohler, H. G. Lancet, 1973, i, 1256. 2. Sandler, B. ibid. 1973, ii, 379. 3. Barrett, C., Hakim, C. ibid. p. 916. 4. Field, B., Kerr, C. ibid. 1974, ii, 1511. 5. W. M. Merrell Co. Production Information Clomid. Cincinnati, Ohio, 1973.
879 enced a similar problem can often reassure and calm a parent in crisis. This help is immediately available and non-threatening (and therefore, perhaps, more readily sought than professional help by a distraught parent), and parents can subsequently be referred with the help of P.A. to the appropriate agency. Parents participating in the scheme say that continuing contact with P.A. helps them to understand their problems and thus to cope with their family situation. 276 Drewry Avenue,
LINDA TU
Willowdale, Ontario, Canada M2M 1E5.
SURVIVAL AFTER DROWNING
SIR,—The important claim of Dr Wind (Oct. 4,
p.
656) con-
cerning recovery of cortical function in a child who survived for 14 hours after drowning in cold water is not, in our view, supported by convincing evidence. The E.E.G. was "virtually isoelectric" at 5 hours after intubation, and the evidence of returning cortical function was believed to be the seizures and the mother’s claim that the infant responded to her. Seizures can occur without a normally functioning cerebral
Parliament
Abortion THE Government’s plans for tightening up on abuses of the abortion law were announced in the House of Commons on Oct. 21. In her statement Mrs BARBARA CASTLE, Secretary of State for Social Services, said that the Government accepted in principle all the recommendations made by the Select Committee which had been considering Mr James White’s Abortion (Amendment) Bill; many of those recommendations had been put forward originally by the Lane Committee on the Working of the Abortion Act. Action had already been taken with the object of requiring private nursing-homes which concentrated on abortion to give an assurance concerning the total fees charged to patients. Assurances had also been sought from all approved nursing-homes about financial arrangements with referral agencies. Only those private nursing-homes with adequate facilities would be authorised to carry out terminations of pregnancy after the 20th week. Nursing-homes had also been asked for information on the number of foreign patients treated during the 18 months to June 30, 1975, and similar information would be sought from all approved nursing-homes at quarterly intervals in future. A review was being made of the arrangements which nursing-homes made for the reception, counselling, and after-care of foreign patients, and changes would be required where necessary. As recommended by the Select Committee, the Health Ministers would be issuing a list of approved referral bureaux, and would refuse to approve clinics which accepted patients from unlisted bureaux; application forms had been issued to bureaux and agencies. A draft paper giving guidance on counselling would be circulated for consultation to bodies representing the medical, nursing, and social-work professions. The Select Committee had recommended that in the N.H.S. terminations after the 20th week of pregnancy should be carried out only in hospitals possessing appropriate facilities, including resuscitation equipment, and this recommendation had been accepted. A circular had been issued to health authorities asking for the adoption of the code of practice of the Peel Advisory Group on the Use of Fetuses and Fetal Material, and a similar request would be put to the private nursing-homes. Some of the other recommendations of the Select Committee would require amendment of the Abortion Regulations of 1968, Mrs Castle went on to say, and the Department of
cortex, and the return of brainstem functions is well recognised in patients with neocortical death’ who may survive for long periods in a vegetative state.2 As Jennett and Plum2 pointed out, reflex responses at spinal or brainstem level can be interpreted by "a hopeful family" as "purposeful or voluntary". In contrast to the cases previously reported3in which rectal temperature was 25°C, the degree of hypothermia (35OC) at the time of hypoxia in this case could not have afforded significant protection for the brain. The available evidence indicates that a child’s brain and heart could be deprived of oxygen for half-an-hour and regain their function only if there had been considerable hypothermia. Section of Neurological Sciences, The London Hospital, London E1 1BB, and Medical Research Council Laboratories,
PAMELA F. PRIOR
Carshalton, Surrey.
J. B. BRIERLEY
1.
Brierley, J. B., Adams, J. H., Graham, D. I., Simpson, J. A. Lancet, 1971, ii, 560. 2. Jennett, B., Plum, F. ibid. 1972, i, 734. 3. Siebke, H., Breivik, H., Rød, T., Lind, B. ibid. 1975, i, 1275. 4. Kvittingen, T. D., Naess, A. Br. med. J. 1963, i, 1315.
Health would be considering the whole question of the procedure for the certification and notification of abortions. It had already been decided, however, that the Regulations would be amended to allow the disclosure to the General Medical Council, on request, of information taken from the notification to the chief medical officers of the Health Departments. It had further been accepted that the Regulations would be amended to ensure that doctors who certified that the conditions of the Abortion Act were met in a particular case should always examine the patient. Guidance had been issued to health authorities on day-care systems, and the Department was hoping to authorise day-care services in some private clinics with a record of high standards. The most important preventive action which the Government had taken was to introduce as part of the N.H.S. a comprehensive family-planning service, which started to function fully this summer. Mrs Castle concluded her statement by explaining that under the procedure whereby Mr White’s Bill had been committed to a Select Committee, the Bill and the Committee would lapse at the end of the present Parliamentary session. The Government felt that Parliament should be given an opportunity to decide whether the Select Committee should be re-established, as the Committee itself had requested, and a motion would be tabled early in the next session. In answer to a question suggesting that hospitals had been directed not to employ obstetricians unless they were willing to carry out abortions, Mrs Castle said that there had been a misunderstanding on this point. Doctors with a conscientious objection to abortion were not being excluded from working in the N.H.S.; however, it had to be accepted that the N.H.S. was under an obligation to provide an abortion service as laid down by Parliament, and if the service was to continue it was essential to ensure that doctors were available to carry out abortions. Of 70 appointments in obstetrics and gynaecology and in anaesthetics made since March 1 this year, there had been only 9 where the need for a willingness to carry out abortions had been specified. Mrs RENEE SHORT asked what exactly the Department had in mind for the women who presented themselves after 20 weeks for a termination of pregnancy; if the Secretary of State intended that they should all be dealt with in N.H.S. hospitals, then a guarantee should be given now that facilities would be made available in every region of the country. Mrs Castle agreed that there were areas of the N.H.S. where facilities were not available for abortions as provided for by legislation; this was connected with the question of doctors and conscientious objections. The Department would do the best it could in difficult circumstances to provide a uniform service.