37

MEAN BIRTH-WEIGHT (g) OF SINGLETONS IN RELATION TOMATERNAL SMOKING

On t testing the mean birth-weight of babies born to non-smokerswere significantly greater than the mean birth-weights of babies bornto 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<O.Ol (mean for smokers 3373 g, N=288).

later. 72% responded.’ This is an exceptionally narrow bandwithin one social class and very homogeneous in regard to in-come and education.The results (see table) show that, in the whole series and

within narrower age and gestation groups, there is a highly sig-nificant fall in mean birth-weight with smoking. There is a fall-ing 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 thelow birth-weight commonly found in babies of smokers is asocial-class effect. Since Yerushalmy’s death, a lot more evi-dence on the effects of maternal smoking on the fetus has beenpublished. Maternal smoking slows tal breathing movementsand is associated with toxic constituents in cord blood.2We would do better to develop new methods of persuading

mothers not to smoke at any time in pregnancy than to reopenthe question of the interference of smoking with fetal growth.We thank Mrs S. Moss for the computation.

Department of Community Health,London School of Hygieneand Tropical Medicine,

London WC1

EVA ALBERMANPETER PHAROAH

Queen Charlotte’s Hospital,London W6 GEOFFREY CHAMBERLAIN

LUNCHTIME GIN AND TONIC

Sm,&mdash;Some people say "my blood-alcohol is low" when

they feel they need a drink, but it is interesting to read, in thepaper 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.

that blood-alcohol concentrations can actually "fall below thelegal limit".

M.R.C. Industrial Injuries and Burns Unit,Birmingham Accident Hospital,Birmingham B15 1NA E. J. L. LOWBURY

WOUND SUTURE AFTER APPENDICECTOMY

SIR,-Mr Foster and his colleagues (May 28, p. 1128) havecompared the results of interrupted nylon skin sutures withsubcuticular polyglycolic acid (P.G.A.). They found that subcu-ticular P.G.A. was significantly more commonly associated withwound sepsis, and concluded that "subcuticular skin suturingcannot be recommended as a method of closure after appen-dicectomy".

Although Mr Foster and his colleagues suggest that a pro-spective trial comparing different types of material might becarried out, I think that their conclusion criticises the methodof suture rather than the material. In my unit for a numberof years abdominal incisions have been closed either with sub-cuticular P.G.A. or with subcuticular polypropylene (’Prolene’).Prolene has given significantly less inflammatory reaction thanP.G.A. although both have been largely satisfactory.

Appendicectomy is more likely to produce wound sepsis thanis gynaecological surgery, but before Mr Foster and his col-leagues condemn the subcuticular suture they should make atrial of the unreactive material prolene, fixing the ends withbeads and lead sinkers and removing the stitch after 5 or 6days. The material is as important as the method.

Birmingham and Midland Hospital for Women,Birmingham B11 4HL WILFRID MILLS

SiR,&mdash;Mr Foster and his colleagues conclude that subcuticu-lar suturing cannot be recommended as a method of closureafter appendicectomy. I do not feel that their data justify thisconclusion. Firstly, Mr Foster and his colleagues compare dif-ferent suture materials in the two closure techniques. Polygly-colic acid, unlike nylon, carries a high risk of tissue reactionand wound erythema when used as a subcuticular or even asubcutaneous suture. One plastic surgeon I know has stoppedusing it in facial surgery for this reason. Secondly, to close theskin with a sealing subcuticular suture after removing a gan-grenous or perforated appendix seems contrary to elementarysurgical principles: a higher infection-rate with the subcuticu-lar suture in this situation cannot be held against the subcuti-cular technique itself.

I have used subcuticular 4-0 nylon closures in many appen-dicectomies, but only if the appendix was not gangrenous orperforated. I am very pleased with the cosmetic results, as aremost of my patients. Unlike Mr Foster and his colleagues I findsubcuticular 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 impor-tant to define terms. A 10% solution of povidone iodine (’Beta-dine’) contains 1% available iodine, which means that 550 mlof such a solution, as used by Strife et al.1 would release 5500mg of available iodine. The intraperitoneal median lethal dose(L.D’50) of povidone iodine in mice is 40-60 mg available

iodine/kg body-weight2,1 (i.e., equivalent to giving a 70 kg man2800-4200 mg of available iodine), In controlled studies ofexperimental peritonitis in mice and rats the therapeutically

1. Strife, C. F., Uhl, M., Morris, D., Fallon, G. Lancet, 1977, i, 1265.2. Gilmore, O. J. A. M.S. thesis, University of London, 1976.3. Gilmore, O. J. A. Ann. R. Coll. Surg. Eng. 1977, 59, 93.

38

effective dose of povidone iodine was found to be 6.0-7.5 mgavailable iodine/kg body-weight, almost ten times less than theL.D.50* Intraperitoneal povidone iodine in this dose significantlyreduced the mortality of both mice and rats with Escherichiacoli peritonitis.3 This therapeutically effective dose is equiva-lent to giving a 70 kg man 42-52 ml of 10% povidone iodinesolution (i.e., over ten times less than that administered byStrife et al. to a 15-year-old child). Despite the amount of povi-done iodine used in this case no abnormality was attributedspecifically to the povidone iodine other than raised serum andurine iodine levels. The abnormal liver-function test (raisedS.G.O.T.) was present preoperatively, and the haematuria andproteinuria were attributed to the high-dose antibiotic therapy.The case reported by Strife et al. seems to be a tribute to thesafety 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 inthe literature about the administration of fluids by the intraos-seous route. This is an old technique that has been well de-scribed in standard works in surgery in this country. I refer

you to one such description.2

Department of P&aelig;diatric Surgery,University of Liverpool,Alder Hey Children’s Hospital,Liverpool L12 2AP R. J. BRERETON

THE CONCEPT "A DISEASE"

SIR,-We are concerned about usages of the names of dis-eases in 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 ofthis with ... a name" (Concise Oxford English Dictionary,1964). One of us has discussed the problems arising from lackof agreement among doctors about what they mean when theyrefer to a disease, and has suggested a definition for use inmedical discourse.3 3

We have made an experimental study of the opinions of doc-tors and of some other groups to find out to what extent theirverbal usages are compatible with this or any other formaldefinition that may be devised. The groups studied include

family doctors practising in Canada, British and Canadianacademic physicians (internists), junior and senior medical stu-dents at McMaster University, Canadian university staff innon-medical faculties, and British (sixth form) and Canadian(grade 12) secondary-school students. The report of this studyis being prepared for publication.

However, we do not want to publish this report until otherswho share our interest have had the opportunity to extend thestudy to other groups of doctors and informed non-medicalpeople, and possibly to offer alternative interpretations to ours.Obviously, once our study is published, particularly if, as wehope, it appears in a widely read journal, further studiesamong doctors may well be biased.

Through your columns we are therefore inviting the partici-pation of others who share our interest and who may be ableto obtain further data. We invite inquiries from people whohave access to groups of the following: non-medical persons ofcomparable educational background to doctors, both scientificand non-scientific; general medical practitioners; physicians(internists) in any specialty; surgeons; psychiatrists and psy-

1. Valdes, M. M. Lancet, 1977, i, 1235.2. Bailey, H. in Bailey and Love’s A Short Practice of Surgery; p. 109. London,

1962.

3. Scadding, J. G. Lancet, 1967, ii, 877.

chologists ; biomedical scientists; and medical students. The in-strument we have used consists of a list of 38 commonly useddiagnostic terms familiar to lay as well as medical English-speaking people on both sides of the Atlantic. It is submittedin the form of a questionnaire to groups of 20-100, and eachprocedure takes about ten minutes.We would be especially pleased to hear from anybody who

is fluently-not just medically-bilingual in English andanother language, and who would be prepared to translate theterms into this language and apply the questionnaire to appro-priate 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. Whenagreement on participation has been reached, the list of terms,the questionnaire sheet, and instructions for the conduct of theexperiment will be sent.

Although the analysis is not complex, Prof. Robin Roberts,of the department of epidemiology and biostatistics, McMasterUniversity, has developed computer programs permitting exam-ination of a number of hypotheses suggested by our findings.We will be pleased to analyse by these methods the dataobtained 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. Participantswill be sent the analysis of their own findings as soon as pos-sible after this date. Those who are able to study groups in lan-guages other than English are urged to write soon, so thattheir 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 subse-quently to prepare another paper based on the data from othercentres and comparisons between these and ours. We shall notpublish the results of all individual studies. However, the pro-cedures detailed above will make the results of each studyavailable to the person who performed it for publication separ-ately, possibly as a challenge to our findings and interpretationin correspondence columns.Department of Medicine,McMaster University,Hamilton, Ontario, Canada

E. J. M. CAMPBELLJ. G. SCADDING*

*Present address: S Astor Close, Kingston Hill, Kingstdn upon Thames, Surrey.

THE ABHORRENCE OF STILLBIRTH

S!R,&mdash;Your editorial’ focused on a very important aspect ofstillbirth.

Insufficient attention is paid to the need for subsequentgenetic counselling, and although the stillbirth is statutorilynotifiable the importance of both post-mortem examinationand X-ray cannot be overemphasised. These two examinationsare complementary if the cause of the stillbirth is to be estab-lished.

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 adequategenetic counselling may simply be a reflection of the attitudeBourne2 found in 1968-i.e., doctors are compulsively reluc-tant to know, notice, or remember anything about motherswhose pregnancies end in stillbirths.

If doctors and allied professionals are to fulfil their rolesthey must attempt to prevent later psychological disability andalso offer genetic counselling for possible future pregnancy.

X-Ray Department,Hospital for Sick Children,London WC1 I. GORDON

1. Lancet, 1977,i,1188.2. Bourne, S.JlR. Coll. gen. Practit. 1968, 16, 103.