medical control over labour
TRANSCRIPT
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 chloram-phenicol before perforation".
It has been our practice to give large doses of intravenouschloramphenicol preoperatively, continue the high doses duringand after operation, and then reduce the dose as the patient im-proves over the first few postoperative days; for example, 1 g. ofchloramphenicol is given at once intravenously, followed by500 mg. 6-hourly intravenously until the patient improves, whenthe dose is reduced to 250 mg. 6-hourly orally when the patientis able to take by mouth. Vitamin-B complex is given intra-venously during the critical stage and is changed to an oralpreparation when the patient takes by mouth. Intravenous fluidsand gastric suction are started urgently and, when indicated, bloodis transfused. In my experience, the patient usually rallies onthe above regimen, and it can almost be said that the outcome ofsurgery depends on the vigour with which these resuscitativemeasures are applied.The OperationSimple closure of the perforation and drainage of the peritoneal
cavity have consistently and predictably given good resdlts.This is not to claim 100% success but to state my consideredopinion that small-bowel resection or other form of radicaloperation as an alternative to simple closure in these criticallyill 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 differentsurgeons", are hardly enough on which to base a treatmentpolicy. This is where the experience of others, particularlyin this part of the world, would be of value.
Department of Surgery,General Hospital,
Oron,South Eastern State,
Nigeria. A. A. OTU.*
* Present address: Department of Bacteriology and Immunology,University of Glasgow, Western Infirmary, Glasgow G11 6NT.
ELECTIVE INDUCTION OF LABOUR
SIR,-The correspondence columns of your journal are asource of great interest to your readers. One week we aretreated to a particular point of view and the next week to thecontrary. We assess contributions and pay attention to the
experience of the departments whence they come and to thereputations of their authors.The letter from the chairman of the Patients Association
(May 10, p. 1088) makes it clear that this organisation isagainst the elective induction of labour, but the letter iswritten with a degree of scholarship and understandingwhich makes it plain that it was prepared by a doctor withan extensive knowledge of the literature. I have no doubtthis doctor is a member of the Patients Association, but wecannot value the contribution as effectively as we shouldlike 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 obstetriciansmore if we knew why that Association was opposed to theinduction of labour. If they can tell us what the patientswould like, we would try to comply.
Strangely enough, the obstetricians and the PatientsAssociation probably have the same common interest-the wellbeing of the patient.
Royal Cornwall Hospital (Treliske),Truro, Cornwall. B. S. Cox.
** * We showed this letter to Mrs Robinson, whosereply follows.-ED. L.
-
SIR,-Mr Cox’s reference to my " scholarship " is
flattering, although the suggestion that I might use someoneelse’s work without acknowledgment is not. I can reassure
him, however. The wee, cowering, timorous obstetrician
thought to be criticising his colleagues whilst shelteringbehind the skirts of the chairman of the Patients Associationis a figment of his imagination. You do not need to be adoctor to acquire an
" extensive " knowledge of the litera-ture. All you need is a good library and a curiosity acquiredby reading over 800 letters from women about inducedbirths. So many of those who could compare an inducedbirth with other births asked whether the doctors reallyknew what they were doing, that I couldn’t resist trying tofind 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 alsoconcerned about the risks which we suspect may exist butwhich have not yet been investigated-for example, thepossible effects on mental health and mother/child relation-ships. Measured in terms of total family morbidity, thepicture may be less satisfactory than many dedicated andcaring obstetricians have yet realised.
Patients Association,335 Gray’s Inn Road,London WC1X 8PX. JEAN ROBINSON.
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 hadrituals about the powerful and important events of child-birth. While it has been claimed that hunting and gatheringcultures, the societal form in which humanity evolved,rarely disturbed " natural " processes, anthropologistsreport that some such groups regularly sought to changelabour’s course. For example, the Mullu Kurumba andthe Malla Ulladan, contemporary tribes in India, manuallylubricate and vigorously dilate the vagina .2 The Chagga ofAfrica perform episiotomies. The Lepcha of Asia and theSiriono of South America stimulate the nipples duringlabour, a procedure known to increase oxytocin release.Many cultures use herbs, some containing oxytocin-likecompounds, to speed delivery.3Contemporary Western culture emphasises control and
domination of physiological processes. With the proclaimedpurpose of improving health, obstetrics offers an ever-
increasing variety of techniques for modifying the onset,duration, pace, and termination of labour. Some womenshare this cultural enthusiasm for control. There are thosewho are relieved that management of a potentially frighten-ing and overwhelming bodily process can be delegated todoctors. Others in the so-called " natural childbirth "
movement, similarly concerned with control, attemptpersonal mastery of labour and delivery by physical andpsychological preparation.
This cultural bias towards control is manifest in youreditorial position-any medical control over labour wouldbe permissible if it were safe. Characteristically, only phy-sical dangers are considered; psychological consequencesare ignored. Without documentation, physicians haveclaimed that women are pleased with doctors’ interventionin childbirth .4, 5 This interpretation of mothers’ reactionsis certainly challenged in the popular literature.’,’,’A woman’s emotional experience of childbirth may be asimportant for her health and that of her child as the
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. 85.6. Robinson, J. Times, Aug. 12, 1974.7. Ladies Home Journal, August, 1970, p. 66.
1243
physical factors involved. The medical profession mighttake time from studying physical effects and techniques ofinduction to evaluate the broader consequences of increasingmedical control over physiology.Division of Geographic Medicine,Department of Medicine, and
Department of Pediatrics,Case Western Reserve University,Cleveland, Ohio 44106, U.S.A.
Anthropological Survey of India,Mysore 2, India.
BETSY LOZOFF.
RAJALAKSHMI MISRA.
GENETIC DISORDERS IN GYPSIES
SIR,—In response to the inquiry by Dr Harper and MrWilliams (May 3, p. 1041) about rare recessive disordersin Gypsy populations in Europe, I should like to recordthe occurrence of citrullinsemia in an inbred Gypsy kindredoriginating from Hungary and Poland, now residing inNorthern Germany. After the birth of the first affectedoffspring of a consanguineous couple (inbreeding coefficientof 009375), I have monitored the next pregnancy. The
prenatal diagnosis, based on a normal 14C-citrulline
incorporation of cultured amniotic-fluid cells in comparisonto known mutant cells, has just been confirmed postnatallyNo other recessive disorder has been observed in thiskindred.
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 reducedurinary excretion of calcium in patients during lithiumtreatment. We have observed similar changes in two
patients treated with lithium. The urinary excretion ofcalcium and phosphate was measured before and after thestart of lithium therapy.
Figs. 1 and 2 show decreased excretion of calcium and
phosphate in the lithium treatment periods, and the de-crease appeared immediately after lithium was first given.During the whole investigation the patients were on a dietcontaining about 30 mmol calcium and 40 mmol phos-
Fig. 1-24-hour urinary calcium excretion in two patientsbefore and after treatment with lithium.
Fig. 2-24-hour urinary phosphate excretion in two patientsbefore and after treatment with lithium.
phorus per day, and this standardisation should excludethe possibility that the changes were due to changes in diet.
In a crossover study of 12 Meniere patients, who wereon and off lithium treatment for two periods of six monthseach, 24-hour urine was collected once in each period.The excretion of calcium in the lithium-free period was7.36±2.29 mmol per 24 hours and during lithium treatment4800-98 mmol per 24 hours (P<0.001).
In a study of calcium and phosphate metabolism, urinaryexcretion alone gives far from a true picture of the totalbalance of these two elements, since most of the excretionof calcium, and about 50% of the excretion of phosphate,takes place via the fseces. A thorough investigation oflithium effects on calcium and phosphate metabolism musttherefore encompass both urinary and fsecal excretion.
Such studies are now in progress in our metabolic ward,and preliminary results indicate that lithium inducesretention of both calcium and phosphate.These long-term effects of lithium are of importance
in relation, among other things, to theories of manic-melancholic disorders focusing on electrolyte disturbances.l
Psychochemistry Institute,Rigshospitalet,9 Blegdamsvej,
DK-2100 Copenhagen,Denmark.
NIELS BJØRUMIB HORNUMERLING T. MELLERUPPER K. PLENGEOLE J. RAFAELSEN.
POLYGLYCOLIC-ACID SUTURES ANDHYPERTROPHIC SCARS
SIR,—I read with interest the paper by Dr Clough andMr Alexander-Williams (Jan. 25, p. 194) and the subsequentcorrespondence on the use of polyglycolic-acid (P.G.A.)sutures for skin closures.
Subcuticular P.G.A. sutures have been used on this unitfor the past five years for all skin closures, including acutesurgery in the presence of sepsis. It has been increasinglyobvious that a proportion of wounds proceed to hyper-trophic scar formation. In our experience, however, thisphenomenon has been confined to those vertical abdominalincisions closed with 00 P.G.A. Transverse abdominalincisions are closed with 000 P.G.A. and thyroidectomy
. incisions and incisions in children with 0000 P.G.A. Manyof these, particularly the thyroid cases, are followed up for
1. Rafaelsen, O. J., Mellerup, E. T. Psychiat. Neurol. Neurochir,Amst. 1973, 76, 523.