"Natural Childbirth"

833

LEADING ARTICLES

incomplete particles and subjected them to electron-microscopic study. The morphological similarity between these incomplete phage particles and the empty heads of the phage particles produced by ANDERSON2 by means of osmotic shock is remarkable. These observations suggest that there must be two processes of intracellular multiplication of phageone leading to the production of the protein shell, and the other to the replication of phage D.N.A. DOUNCE 12 has lately suggested that D.N.A. may not only be responsible for self-replication but may also form a template for protein synthesis. The increasing use of phage for the study of genetic problems is reflected by the number of papers on phage in the recent Cold Spring Harbor symposium 13 ; these’

THE LANCET

.

LONDON:SATURDAY, APRIL 25, 1953

Bacteriophage July, 1952, the first international congress to be devoted entirely to bacteriophages was held at IN

have been pubAt this dealt with workers American particularly meeting methods of phage reproduction, while French workers were concerned more with lysogenicity. Phage multiplication has been intensively studied with the coliphage T2 ;; and this work has been aided by the development of electro-microscopic techniques,2 which have revealed that the head of T2 phage is hexagonal in shape and is composed of a protein shell filled with desoxyribonucleic acid (D.N.A.). ANDERSON et a1.2 suggest that the tail seen in these phages is hollow and attaches the head of the phage to the host-cell. By osmotic shock the D.N.A. has been removed from the head, leaving the protein skeleton behind. Primary attachment of the tailed phages seems to be by means of the tail, probably by electrostatic attraction 3 ; this primary attachment, which is reversible, appears to be the step inhibited by antisera. HERSHEY and CHASE4 have shown that the subsequent irreversible change leading to infection is due to the passage of D.N.A. into the host. Most of the phage protein remains outside the cell and appears in a form similar to the skeletons seen by ANDERSON and his colleagues.2 Thus the protein fraction appears to act as a syringe which injects the phage D.N.A. into the host-cell. Possibly there is a similar type of union between human viruses and their host-cells ;; but it would be unwise to suggest close analogies between phage and human viruses. Once inside the cell the reproduction and the genetic pattern of the phage are apparently controlled by the D.N.A. By means of radioactive isotopes several investigators have found that, while up to 30% of the infecting particle’s nucleic acid is transferred to its progeny, little or no protein is similarly transferred. 6 It is noteworthy that WYATT and COHEN 7 have shown that the phage D.N.A. is chemically distinct from that of its host, while the work of KNIGHT8 suggests that, in animal viruses at least, the protein pattern is in part a reflection of the host species. This might be expected, since it appears that phage protein is synthesised partly from the metabolic pool in the bacterial cell. LEVINTHAL and FISHER9 have observed what they believe to be incomplete virus particles in cells that were prematurely lysed ; and DE MARS et al.,10 making use of the observation by FOSTER 11 that proflavine prevented the production of complete phage but did not prevent cellular lvsis. produced large numbers of

Royaumont;

and the

proceedings

lished in the Annales de l’Institut Pasteur.l

1 Ann. Inst.

Pasteur, 1953, 84,

1.

2. Anderson, T. F.,F., Rappaport, C., Muscatine, N. A. Ibid, p. 5. 3. Puck T.T.,Garen,A., Cline, J. J. exp. Med. 1951, 94, 177. 4. Hershey, A.

D., Chase, M.

J. gen. Physiol.

F. Ann. Inst. Pasteur. 5.Hershey, Graham,A.A.A. D. Ibid, p. 99. 6.

1952, 36, 39. 1953, 84, 90.

G. R., Cohen, S. S. Ibid, p. 143. 7. Wyatt,C. A.J. exp.Med. 1946,83, 281. 8. Knight, Biochim. biophys. Acta, 1952, 9, 597. 9. Levinthal, C., 10. De R. Fisher, Luria, H.S.E.,Fisher,H.,Levinthal, C. Ann. Mars, Inst. Pasteur,I., 1953,84, 113.

11. Foster,

R. A. C.

J. Bact. 1948, 56, 795.

and it

seems

that, because of the

ease

with which it is

rapidity of its multiplication, it may become as important a tool as drosophila in the study of genetic problems. Since the initial observation on phage mating by DELBRUCK and BAILEY 14 a manipulated

and the

mass of data has been accumulated. To this ADAMS 15 has added information on heat-resistant phage mutants, and LURIA and HUMAN 16 on host-induced mutants. On the technical side the observations of BRESCH 17 on the use of dyes to differentiate plaquetype mutants may prove very useful. Unfortunately all these observations are unlikely to be fully explained until the exact mechanism of phage multiplication is fully elucidated. Meanwhile, however, VISCONTI 18 has put forward a new theory of phage genetics that covers most of the observed facts. As regards lysogenicity BERTArm 19 has observed that mutual exclusion, which is a feature of lytic phages, also occurs with the prophage forms ; and he believes that his results can be most readily explained by assuming that prophages form an integral part of the genetic structure of the host-cell and are transmitted at each cell division. WOLLMAN 20 also believes that the prophages are genetically linked ; but he suggests that prophage may be a form of cytoplasmic inheritance. In this connection it should be borne in mind that ZrnDER and LEDERBERG 21 have transmitted genetic characters from one cell to another by means of bacteriophages. In considering work on phages it is well to remember that these organisms are probably of much greater value for the study of individual problems of virus multiplication and genetics than as models on which to base generalisations about the behaviour of virusesas a class. "

"Natural Childbirth THERE are two ways of investigating attitudes - boy tabulating the answers of thousands of people to a few questions, or by making detailed inquiries into the views of a few. By this second method FREEDMAN et al.22 at Yale, have found that the recent memory of twenty mothers for the events of labour 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22.

was

much the

same as

that of their

attendants ;

Dounce, A. L. Enzymologia, 1952, 15, 251. Cold Spr. Harb. Symp. quant. Biol. 1951, 16. Delbruek, M., Bailey, W. T. Ibid, 1946, 11, 67. Adams, M. H. Ann. Inst. Pasteur, 1953, 84, 164. Luria, S. E., Human, M. L. J. Bact. 1952, 64, 557. Bresch, C. Ann. Inst. Pasteur, 1953, 84, 157. Visconti, N. Ibid, p. 180. Bertani, G. Ibid, p. 273. Wollman, E. Ibid, p. 281. Zinder, N. D., Lederberg, J. J. Bact. 1952, 64, 679. Freedman, L. Z., Redlich, F. C., Eron L. D., Jackson, Psychosom Med. 1952, 14, 431.

E. B.

834

and thereby they expose a fiction which has sustained the opponents of analgesia since the days of SIMPSON. The old saying that " after all they forget the whole thing " contains a germ of truth which relates only to the quality and perhaps the full intensity of pain. Recollected pain can seldom be described, for it cannot be recalled in the sensorium as can visual or auditory images ; and at a second or later labour women are sometimes heard to say : " I remembered that it was bad last time ; now I remember how awful it was." FREEDMAN’S paper also underlines the fact that childbirth is especially remembered as an important event, though this memory, which is the pivot to less important ones, may be distorted by self-justification and by later experience. The patients studied by the Yale workers were all participating in the Newhaven " natural childbirth " programme.23 " Natural childbirth " is an attractive but misleading title ; for the main aim of the Newhaven and similar schemes-for example, that of Prof. W. C. W. Nixorr at University College Hospital, London-is to make delivery as easy and tolerable as possible within the limits of safe analgesia. Much skill is required to ensure really effective analgesia in labour ; this cannot always be provided in hospital, let alone in the home. These schemes, though differing in detail, consist essentially of two parts : first, a psychophysical preparation for childbirth ; and secondly, a labour-ward technique. The first part is directed at giving the woman confidence in her own powers-the sort of self-confidence that was signally lacking in the days when society and the medical profession kept her in ignorance. Thus lectures on various aspects of normal childbirth are combined with a small amount of physical training. The lectures cover the development of the child, the process of birth, breast-feeding, and baby-craft. The physical training, carefully dovetailed with the lectures, consists in postural adjustment to the strains of pregnancy, relaxation, and breathing exercises. With the exercises evolved by the late HELEN HEARDMAN 24 the woman also learns pelvic rocking, and accustoms herself to the lithotomy position. She should also get to know the hospital and its staff and familiarise herself with the analgesic apparatus. NIXON 25 thinks that as regards labour the most important part of the programme is the labourward technique. In the labour ward the woman is encouraged to rely on her own powers, by making and she is never use of the things she has learnt ; left alone-thus averting an experience that has frightened many. Like any other prophylaxis this programme does not deal with established disease. As MANDY et al.26 rightly point out, the seriously disturbed woman needs treatment as well as natural childbirth " ; sexual disturbances, for example, which are widespread in our population and can have important sequelae in labour,27-29 are not dealt with in the classes. Most of the critics of ’’natural childbirth " programmes tend to assess their value purely in terms of "

23. Thorns, H. Training for Childbirth. New York, 1950. 24. Heardman, H. The Way to Natural Childbirth. Edinburgh, 1948. Personal communication. 25. Nixon, W. C. W. 26. Mandy, A. J., Mandy, T. E., Farkas, R., Scher, E. Psychosom. Med. 1952, 14, 431. 27. Tylden, E. Lancet, 1952, i, 231. 28. O’Neill, D. Postgrad, med. J. 1950, 26. 64 ; Ibid, 1951, 27, 468. 29. Tylden, E. Nursing Times, Feb. 17, 1951.

the effect of the classes on the course of labour263o; and commonly they judge this only in terms of mechanical factors, ignoring emotional factors. Perhaps this is partly the fault of some who, writing on the physiotherapeutic aspects, seem to have concentrated on statistics covering mechanical factors, in an attempt to appeal to the " obstetrician-in-the-street." There has been far too little research into emotional aspects and psychophysical mechanisms, and virtually no research into either the need for antenatal classes or their effects. WOODWARD,31 however, has inquired into the attitudes of 100 pregnant women who were attending antenatal clinics but not classes in natural childbirth. She found that in the life of a woman loneliness and apprehension were ordinarily at their peak from the fourth month of her first pregnancy, when she leaves work and faces a lonely existence, a lower income, and the unknown terrors of confinement. WOODWARD’S findings would lead one to suppose that women who have attended classes would come to labour better prepared after a happier and less tense pregnancy. Regimentation of the patient and dependence by her on an authoritative figure has long been the basis of conventional maternity obstetric practice 27; but it has no place in natural childbirth. The divergence between the two systems is evident at every medical discussion of the subject.3o "Natural childbirth" programmes represent one of the first attempts to practise a preventive medicine that recognises the unity of body and mind, by combining health education, group discussion, participation, and psychological techniques. This promising approach, which GRANTLY DICK READ 32 has done much to promote, has captured the attention of the public, and is thus being given a fair chance to develop ; and authority, which is playing its traditional role, is failing to put the clock back. "

Blood-clotting AT last year’s International Conference of Hsematology, held in Argentina, the research-workers on blood-clotting held a separate meeting to discuss their difficulties. Such a meeting was necessary because progress towards a better understanding of bloodclotting and its disorders was becoming obscured by a. fog of nomenclature ; everybody seemed to have their own name for the various factors" " concerned in clotting, and new ones were being added before the old ones were properly understood. Some efforts towards resolving the confusion have now been made, and it is clear that the factors are nothing like so The fifth numerous as the literature might suggest. conference on blood-clotting held by the Josiah Macy, Jr., Foundation in New York set up a committee which has published 33 a list of synonyms for the so-called prothrombin accelerators-factor v of Owren and factor vn of Koller. STEFANINI,34 in a review of present ideas, has compiled a more comprehensive list. He points out that most workers at present agree that blood-coagulation has three stages : (1) activation of thromboplastin ; (2) conversion of prothrombin to 30. Proc. R. Soc. Med. 1950, 43, 27. 31. Woodward, M. British Association, Belfast, 1952 ; section J. 32. Read, G. D. Natural Childbirth. London, 1933 ; Lancet, 1949, i, 721. 33. Alexander, B., Plynn, J. E., Mann, F. D., Owren, P. A., Seegers, W. H. Trans. 5th Conf. on Blood Clotting. Josiah Macy, Jr.,

Foundation, 1952 ; p. 329. 34. Stefanini, M.

Amer. J. Med.

1953, 14, 64.