BRITISH MEDICAL JOURNAL
389
11 AUGUST 1979
principle for the clinician to develop. Similar work, satisfaction, and usefulness can be found not only in mission hospitals but also in government service in training or health centres or hospitals. Lastly there should be a clearing house for posts in and personnel for medical jobs in poorer countries. Would anyone interested in the idea please let me know? C J BURNS-COX Department of General Medicine, Frenchay Hospital, Bristol BS16 ILE
SIR,-As one of the holders of Dr Anne Savage's BTAf (Been to Africa) (14 July, p 111), I wish to congratulate her on an excellent article. She conveys admirably the various aspects of mission hospital work and I hope the article will inspire other doctors in training to undertake similar overseas activities. One of the greatest worries facing a junior doctor wishing to spend a period of time abroad is his concern that a place on the career ladder at home will be lost. This is a very real problem and enough to deter all but the most enthusiastic. Dr Savage's suggestion of a central register is an excellent one, but its purpose must clearly be twofold: to find doctors to fill the many vacant posts in mission hospitals and to help those currently working overseas to find suitable posts on returning to the United Kingdom. My own specialty of obstetrics and gynaecology is one which particularly lends itself to a term overseas. We are all required to spend an elective year in another specialty or in a completely different environment. The Royal College of Obstetricians and Gynaecologists accepted my year working with a general surgeon in a mission hospital in the Ivory Coast. When the time for us to leave was approaching the hospital wrote to the college asking them if they could find a replacement for me. We received a very courteous reply, but alas no surgeon. I am sure there are many other doctors working at home and abroad who share Dr Savage's views. I should very much like to see them making use of these columns to publicise their support so that some positive action can be taken to improve the security, respectability, and number of BTAfs. C J CHANDLER Hospital for Women, Leeds LS8 1NT
Severe hypernatraemia in adults SIR,-We would like to support several of the points made by Dr P Daggett and others in regard to hypernatraemia in patients with hyperosmolar non-ketotic diabetic coma (5 May, p 1177). We have retrospectively reviewed the 18 patients admitted to the Royal Adelaide Hospital with hyperosmolar coma over a seven-year period (1969-76). All of the eight patients who died were over 60 and had a 350 mmol (mosm)/l. serum osmolarity Hyperglycaemia was easily controlled in all 18 patients but the serum sodium concentration and osmolarity took several days to return to normal. In 14 patients (78",, ) there was an initial increase in the serum sodium concentration and in three (170%) the serum osmolarity also increased with therapy. This aggravation of the hyperosmolar state was
attributable to an excessive sodium load, since at that time intravenous fluid therapy consisted of 0 9'" sodium chloride or alternating 0 90% and 0 45'% sodium chloride. We now believe that immediate therapy should correct hypovolaemia using plasma expanders and that subsequent therapy should replace over a 48-hour period: (a) the water deficit as 5)° dextrose (estimated from the corrected plasma sodium concentration'); (b) the sodium deficit (some 400 mmol (mEq))2 as 0-9%, sodium chloride; (c) the urine losses initially as 0 45"% sodium chloride and then as indicated by urine sodium content. Provided the plasma glucose concentration is kept above 12 mmol/l (216 mg/100 ml) the brain will adapt to the gradual decrease in extracellular osmolarity.3 Such a regimen will avoid aggravation or prolongation of the hyperosmolar state, which is the main cause of coma, brain damage, and death in these patients.4 The data reported by Daggett et al largely support this regimen. In their patients the serum sodium concentration increased and the serum osmolarity did not change until 5%' dextrose was used. They suggest that a hypoosmolar intravenous solution to replace water is needed but perhaps forget that 5%0 dextrose is effectively converted to water as the glucose is removed by the cells and that 5%,, dextrose is iso-osmolar when given. We would like to reinforce their point that generally less sodium and more water is required in the treatment of hyperosmolar non-ketotic diabetic coma. P J PHILLIPS Institute of Medical and Veterinary Science, Adelaide, South Australia 5000
L B To Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, South Australia 5000
Crandall, E D, England Journal of Medicine, 1974, 290, 465. 2Arieff, A I, and Carroll, H J, Medicine, 1972, 51, 73. 3Guisado, R, and Arieff, A I, Metabolism, 1975, 24, 665. ' Fulop, M, et al, Diabetes, 1975, 24, 594.
Abortion
SIR,-I hope Mr Victor Tunkel's paper (28 July, p 253) on certain widely ignored legal aspects of abortion (which should surely have been titled "De minimis curat lex") will not be neglected. His suggestion that we "face the reality that IUDs are illegal in all circumstances" supports the view I have expressed on several occasions.'-3 He seems, however, to have partly ignored his own argument in suggesting a localised "non-controversial reform ... to put beyond prosecution" the precoital or postcoital insertion of IUDs, and perhaps menstrual extraction as well. If he accepts that these methods do involve the destruction or dislodging of tiny fetuses, what legal, moral, or medical criteria would he have us use to distinguish between abortion at two hours or two days and abortion at two weeks or two months ? Surely such a distinction can be only an aesthetic one. If the IUD and-a fortiorimenstrual extraction are to be freed from legal restriction, should not that logically be the case for all abortion up to the stage when, as he rightly says, it becomes quasi-infanticide ? Conversely, those in and out of Parliament who oppose abortion because they see it as destroying established human life must be made to state publicly whether they are equally opposed to the IUD, and if not, why not.
Indeed, I urge your readers to put this question to their MPs. They will have the pleasure of forcing anti-abortionists to choose between being manifestly inconsistent or wanting to restrict an effective and widely used birth control method out of an obsessive concern for microscopic forms of life which many electors will find absurd. Most, of course, will simply evade the issue; but their evasiveness can be made public. And if they argue that perhaps life does not begin at conception but at some later point (shades of "ensoulment" at 40 days for men and 80 for women), well, two can play at that game. Abortion is a moral issue, and I am all for fighting the moralisers on their own ground. If Mr Tunkel is right, the argument about the IUD is one which anti-abortionists cannot win and cannot afford to lose, and the publication of his paper in a leading medical journal is a belated recognition of its potential importance in the present rerun of the Great Abortion Debate. COLIN BREWER London NW8 I
2
Brewer, C, World Medicine, 1976, 11, 33. Brewer, C, British Medical Journal, 1977, 1, 169.
3Brewer, C, World Medicine, 1978, 13, 53.
SIR,-Mr Victor Tunkel remarks (28 July, p 253) that it is surprising how "doctors, hospital and health authorities seem to be in ignorance of the law." I should like to suggest that it is not "ignorance" but the interpretation of the law that is at issue. In the debate on the Infant Life (Preservation) Bill in the House of Lords in November 1928, Lord Hailsham, the Lord Chancellor (father of the present holder of that office), observed that for "complete birth" it was not enough to prove that a child had "breathed": "You also had to prove that there had been an independent circulation in the child before it could be counted alive."' This suggests that the Redbridge and Waltham Forest Area Health Authority was perfectly correct in concluding that the Wanstead fetus was "incapable of sustaining life" (this was the critical factor in the case), and that "emitting noises" and other such transient manifestations that mimic life were not relevant considerations in determining whether or not a fetus can be "counted alive." The real issue for the concerned public, if not perhaps for the lawyers, is what ought to be the proper criteria for counting a child "alive" in a meaningful as opposed to a literal and irrelevant sense. MADELEINE SIMMS London NW11 8AG I
Simms, M, New Humanist, 1979, 95.
SIR,-When the House of Commons is again wasting time on the latest attempt to alter the Abortion Act, it is refreshing to hear them being told this by your leading article (28 July, p 230). The House's misguidance is matched only by the ignorance of Mr John Corrie, who in his comments to the media and wording of his Bill showed a frightening lack of understanding of his chosen subject. Your article fails to emphasise that a main aim of Mr Corrie is to reduce substantially the number of terminations by altering the wording of the clause on conditions. Changes such as this are likely to lead many who cannot afford
389
11 AUGUST 1979
principle for the clinician to develop. Similar work, satisfaction, and usefulness can be found not only in mission hospitals but also in government service in training or health centres or hospitals. Lastly there should be a clearing house for posts in and personnel for medical jobs in poorer countries. Would anyone interested in the idea please let me know? C J BURNS-COX Department of General Medicine, Frenchay Hospital, Bristol BS16 ILE
SIR,-As one of the holders of Dr Anne Savage's BTAf (Been to Africa) (14 July, p 111), I wish to congratulate her on an excellent article. She conveys admirably the various aspects of mission hospital work and I hope the article will inspire other doctors in training to undertake similar overseas activities. One of the greatest worries facing a junior doctor wishing to spend a period of time abroad is his concern that a place on the career ladder at home will be lost. This is a very real problem and enough to deter all but the most enthusiastic. Dr Savage's suggestion of a central register is an excellent one, but its purpose must clearly be twofold: to find doctors to fill the many vacant posts in mission hospitals and to help those currently working overseas to find suitable posts on returning to the United Kingdom. My own specialty of obstetrics and gynaecology is one which particularly lends itself to a term overseas. We are all required to spend an elective year in another specialty or in a completely different environment. The Royal College of Obstetricians and Gynaecologists accepted my year working with a general surgeon in a mission hospital in the Ivory Coast. When the time for us to leave was approaching the hospital wrote to the college asking them if they could find a replacement for me. We received a very courteous reply, but alas no surgeon. I am sure there are many other doctors working at home and abroad who share Dr Savage's views. I should very much like to see them making use of these columns to publicise their support so that some positive action can be taken to improve the security, respectability, and number of BTAfs. C J CHANDLER Hospital for Women, Leeds LS8 1NT
Severe hypernatraemia in adults SIR,-We would like to support several of the points made by Dr P Daggett and others in regard to hypernatraemia in patients with hyperosmolar non-ketotic diabetic coma (5 May, p 1177). We have retrospectively reviewed the 18 patients admitted to the Royal Adelaide Hospital with hyperosmolar coma over a seven-year period (1969-76). All of the eight patients who died were over 60 and had a 350 mmol (mosm)/l. serum osmolarity Hyperglycaemia was easily controlled in all 18 patients but the serum sodium concentration and osmolarity took several days to return to normal. In 14 patients (78",, ) there was an initial increase in the serum sodium concentration and in three (170%) the serum osmolarity also increased with therapy. This aggravation of the hyperosmolar state was
attributable to an excessive sodium load, since at that time intravenous fluid therapy consisted of 0 9'" sodium chloride or alternating 0 90% and 0 45'% sodium chloride. We now believe that immediate therapy should correct hypovolaemia using plasma expanders and that subsequent therapy should replace over a 48-hour period: (a) the water deficit as 5)° dextrose (estimated from the corrected plasma sodium concentration'); (b) the sodium deficit (some 400 mmol (mEq))2 as 0-9%, sodium chloride; (c) the urine losses initially as 0 45"% sodium chloride and then as indicated by urine sodium content. Provided the plasma glucose concentration is kept above 12 mmol/l (216 mg/100 ml) the brain will adapt to the gradual decrease in extracellular osmolarity.3 Such a regimen will avoid aggravation or prolongation of the hyperosmolar state, which is the main cause of coma, brain damage, and death in these patients.4 The data reported by Daggett et al largely support this regimen. In their patients the serum sodium concentration increased and the serum osmolarity did not change until 5%' dextrose was used. They suggest that a hypoosmolar intravenous solution to replace water is needed but perhaps forget that 5%0 dextrose is effectively converted to water as the glucose is removed by the cells and that 5%,, dextrose is iso-osmolar when given. We would like to reinforce their point that generally less sodium and more water is required in the treatment of hyperosmolar non-ketotic diabetic coma. P J PHILLIPS Institute of Medical and Veterinary Science, Adelaide, South Australia 5000
L B To Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, South Australia 5000
Crandall, E D, England Journal of Medicine, 1974, 290, 465. 2Arieff, A I, and Carroll, H J, Medicine, 1972, 51, 73. 3Guisado, R, and Arieff, A I, Metabolism, 1975, 24, 665. ' Fulop, M, et al, Diabetes, 1975, 24, 594.
Abortion
SIR,-I hope Mr Victor Tunkel's paper (28 July, p 253) on certain widely ignored legal aspects of abortion (which should surely have been titled "De minimis curat lex") will not be neglected. His suggestion that we "face the reality that IUDs are illegal in all circumstances" supports the view I have expressed on several occasions.'-3 He seems, however, to have partly ignored his own argument in suggesting a localised "non-controversial reform ... to put beyond prosecution" the precoital or postcoital insertion of IUDs, and perhaps menstrual extraction as well. If he accepts that these methods do involve the destruction or dislodging of tiny fetuses, what legal, moral, or medical criteria would he have us use to distinguish between abortion at two hours or two days and abortion at two weeks or two months ? Surely such a distinction can be only an aesthetic one. If the IUD and-a fortiorimenstrual extraction are to be freed from legal restriction, should not that logically be the case for all abortion up to the stage when, as he rightly says, it becomes quasi-infanticide ? Conversely, those in and out of Parliament who oppose abortion because they see it as destroying established human life must be made to state publicly whether they are equally opposed to the IUD, and if not, why not.
Indeed, I urge your readers to put this question to their MPs. They will have the pleasure of forcing anti-abortionists to choose between being manifestly inconsistent or wanting to restrict an effective and widely used birth control method out of an obsessive concern for microscopic forms of life which many electors will find absurd. Most, of course, will simply evade the issue; but their evasiveness can be made public. And if they argue that perhaps life does not begin at conception but at some later point (shades of "ensoulment" at 40 days for men and 80 for women), well, two can play at that game. Abortion is a moral issue, and I am all for fighting the moralisers on their own ground. If Mr Tunkel is right, the argument about the IUD is one which anti-abortionists cannot win and cannot afford to lose, and the publication of his paper in a leading medical journal is a belated recognition of its potential importance in the present rerun of the Great Abortion Debate. COLIN BREWER London NW8 I
2
Brewer, C, World Medicine, 1976, 11, 33. Brewer, C, British Medical Journal, 1977, 1, 169.
3Brewer, C, World Medicine, 1978, 13, 53.
SIR,-Mr Victor Tunkel remarks (28 July, p 253) that it is surprising how "doctors, hospital and health authorities seem to be in ignorance of the law." I should like to suggest that it is not "ignorance" but the interpretation of the law that is at issue. In the debate on the Infant Life (Preservation) Bill in the House of Lords in November 1928, Lord Hailsham, the Lord Chancellor (father of the present holder of that office), observed that for "complete birth" it was not enough to prove that a child had "breathed": "You also had to prove that there had been an independent circulation in the child before it could be counted alive."' This suggests that the Redbridge and Waltham Forest Area Health Authority was perfectly correct in concluding that the Wanstead fetus was "incapable of sustaining life" (this was the critical factor in the case), and that "emitting noises" and other such transient manifestations that mimic life were not relevant considerations in determining whether or not a fetus can be "counted alive." The real issue for the concerned public, if not perhaps for the lawyers, is what ought to be the proper criteria for counting a child "alive" in a meaningful as opposed to a literal and irrelevant sense. MADELEINE SIMMS London NW11 8AG I
Simms, M, New Humanist, 1979, 95.
SIR,-When the House of Commons is again wasting time on the latest attempt to alter the Abortion Act, it is refreshing to hear them being told this by your leading article (28 July, p 230). The House's misguidance is matched only by the ignorance of Mr John Corrie, who in his comments to the media and wording of his Bill showed a frightening lack of understanding of his chosen subject. Your article fails to emphasise that a main aim of Mr Corrie is to reduce substantially the number of terminations by altering the wording of the clause on conditions. Changes such as this are likely to lead many who cannot afford
