1513
investigations. We consider that these problems need addressed before concluding that "more is always better"
to be in the
present financial climate. Centre for Health Services Studies, The University, Canterbury, Kent CT2 7NF, UK
L.
J. OPIT
Kent and
Canterbury Hospital, Canterbury
R. E. C. COLLINS
1. A short cut to better services: day surgery in England and Wales. Audit Commission for Local Authorities and the National Health Service. London. HM Stationery Office, 1990. 2. The management and utilisation of operating departments. NHS Management Executive. London: HM Stationery Office, 1989
SIR,-As a "fit" female surgeon and a mother who has lately had an
arthroscopic meniscectomy as a day case I offer a warning about’ day-stay surgery (Nov 3, p 1118 and p 1123). I realise that this is the latest scheme to save the ailing National Health Service millions of pounds, but there will be a striking increase in morbidity and a lengthening of the recovery time if mothers are thus treated. For instance, if on the mother’s return home after day care a child says "Mum where are my football things?" the mother will get up and find them, or if a young child cries in the night it is the mother who is wanted, not the father. If the mother is not there the family will cope, but if she is she will not have the rest she needs. Were any of Howard Davies’s colleagues who were on the Audit Commission that produced the document on day surgery female? Furthermore, I disagree that large amounts of money would have to be spent developing special day-stay units with separate operating theatres to achieve a high proportion of day-case surgery-this would merely require efficient organisation. During the past two years while working in a district general hospital with no day-care facility, 37 % of patients on my lists have been treated as day cases. These have all been admitted to the normal ward, had general anaesthetics in the routine theatre during the morning lists, and been discharged the same afternoon. Needless to say, virtually all these patients have been children or men. Hull
Royal Infirmary,
CAROL WENGRAF
Hull HU3 2JZ, UK
interested parties and indeed the Royal College document was circulated to all Members of Parliament as a part of its campaign against abortion law reform. Although admitting that estimates varied between their own of 14 600 yearly up to 250 000,2 the Council based its calculation largely on the number of deaths recorded as due to illegal abortion. They also assumed that patients of criminal abortionists would have a higher mortality than would those of gynaecologists who were doing legal abortions. This argument gained little support outside the 25 people at the council
meeting. Because abortion was the most important single cause of maternal death, the Family Planning Association held a conference, chaired by Lord Brain, in April, 1966.3 Here Prof Philip Rhodes estimated from his own experience that there were about 86 000 criminal abortions per year in England and Wales but added "For the sake of argument I shall take the figure of 100 000 which has come to be widely accepted". Rhodes also demonstrated that illegal abortion was only about twice as dangerous as full-term pregnancy-far below the RCOG estimate. Thus, the sudden large increase in legal abortions in 1969 would have reduced livebirths substantially had it not followed an equally large number of illegal abortions, before that date. It is
important to remember that there were a large number of illegal abortions, but because of the great success of the 1967 Act criminal abortion has been virtually eliminated and maternal mortality has been strikingly reduced. We must accept that considerable numbers of therapeutic abortions will still be needed until contraception is more widely accepted and efficiently used. 10 Campden Hill Square, London W8 7LB, UK
PETER DIGGORY
Legalised abortion: a report by the Council of the Royal College of Obstetricians and Gynaecologists. Br Med J 1966; i: 850-54. 2. Chesser E. Cited by M. Pearson. Sunday Telegraph Jan 30, 1966, p 25. 3. Abortion in Britain. Proceedings of a conference held by the Family Planning Association on April 22, 1966. London: Pitman Medical, 1966. 1.
Clinical trials in
paediatrics
SIR, Medical Letter has lately published a note on sudden deaths at least three children treated with a tricyclic antidepressant (desipramine) and with plasma concentrations below the toxic ranged Children may be more susceptible than adults to cardiac toxicity from these drugs because of differences in pharmacokinetics. In our general hospital, with 585 beds, an annual average total of thirty-four projects for clinical trials comes before the ethics committee for approval. Only two are studies in children, and no study has been for a phase I clinical trial in children. Responsiveness to drugs is altered in children, mainly due to pharmacokineticsNevertheless it is commonly held that clinical
in
Abortion SIR,-When considering the possible consequences of permissive legislation on euthanasia Dr Twycross (Sept 29, p 796) referred to the increase in social abortion that followed the 1967 Abortion Act. Mr Diggory (Oct 20, p 1013), somewhat illogically, dismisses this concern with the statement that the principal aim of the Abortion Bill "was to reduce the very large number of criminal abortions then being done" and he cites 100 000 per annum in England and Wales as the estimate of the then Home Secretary. In 1966, the Council of the Royal College of Obstetricians and Gynaecologists, in its report on legalised abortion, considered the relevant reports on confidential inquiries into maternal deaths in England and Wales and the hospital inpatient inquiry and concluded that the number of criminal abortions in England and Wales, including those induced by women themselves, was less than 15 000 per annum. It is remarkable that 23 years on, with the annual abortion figure approaching 200 000, Diggory should quote a politician’s estimate rather than that of the Council of his own College to justify the 1967 Abortion Act. If euthanasia is being practised illegally in this country it would be disingenuous to suppose that its legalisation could not be followed by the same order of escalation as has occurred with abortion. 24 St Brannocks Road, Chorlton, Manchester M21 1UP, UK
*t* This
letter has been shown
JOHN MCLEAN to
Mr
Diggory,
whose
reply
follows.-ED. L.
SIR,—Why did I quote the Home Secretary’s estimate and omit that made by the Council of the Royal College of Obstetricians?1 The Home Secretary had access to large numbers of estimates by
trials in children should not be done for ethical reasons. As a result paediatricians use doses extrapolated from data on adults. More clinical trials should be done in paediatrics, to avoid risks when treating children with drugs. Clinical
Pharmacology Service, Hospital Germans Trias i Pujol, Autonomous University of Barcelona, Badalune (Barcelona), Spain
P. SALVA M. A. AGUADO
1. Anon. Sudden death in children treated with a tricyclic anti-depressant. Med Lett Drugs Ther 1990; 32: 53. 2. Robinson DS, Barker E. Tncyclic antidepressant cardiotoxicity. JAMA 1987; 236: 2089-90.
Rhabdomyolysis and temperature SIR,-Dr Cook and colleagues (Nov 3, p 1136) report nontraumatic rhabdomyolysis in a 37-year-old man, which they attribute to radiant heating (sunlight shining through glass shop windows) and convective heating (contact with air heated by sunlight). Our experience of over 700 clinical whole-body hyperthermia treatments suggests that it is unlikely that radiant and convective heating could account for this man’s rhabdomyolysis. We routinely heat cancer patients to a body core temperature of
investigations. We consider that these problems need addressed before concluding that "more is always better"
to be in the
present financial climate. Centre for Health Services Studies, The University, Canterbury, Kent CT2 7NF, UK
L.
J. OPIT
Kent and
Canterbury Hospital, Canterbury
R. E. C. COLLINS
1. A short cut to better services: day surgery in England and Wales. Audit Commission for Local Authorities and the National Health Service. London. HM Stationery Office, 1990. 2. The management and utilisation of operating departments. NHS Management Executive. London: HM Stationery Office, 1989
SIR,-As a "fit" female surgeon and a mother who has lately had an
arthroscopic meniscectomy as a day case I offer a warning about’ day-stay surgery (Nov 3, p 1118 and p 1123). I realise that this is the latest scheme to save the ailing National Health Service millions of pounds, but there will be a striking increase in morbidity and a lengthening of the recovery time if mothers are thus treated. For instance, if on the mother’s return home after day care a child says "Mum where are my football things?" the mother will get up and find them, or if a young child cries in the night it is the mother who is wanted, not the father. If the mother is not there the family will cope, but if she is she will not have the rest she needs. Were any of Howard Davies’s colleagues who were on the Audit Commission that produced the document on day surgery female? Furthermore, I disagree that large amounts of money would have to be spent developing special day-stay units with separate operating theatres to achieve a high proportion of day-case surgery-this would merely require efficient organisation. During the past two years while working in a district general hospital with no day-care facility, 37 % of patients on my lists have been treated as day cases. These have all been admitted to the normal ward, had general anaesthetics in the routine theatre during the morning lists, and been discharged the same afternoon. Needless to say, virtually all these patients have been children or men. Hull
Royal Infirmary,
CAROL WENGRAF
Hull HU3 2JZ, UK
interested parties and indeed the Royal College document was circulated to all Members of Parliament as a part of its campaign against abortion law reform. Although admitting that estimates varied between their own of 14 600 yearly up to 250 000,2 the Council based its calculation largely on the number of deaths recorded as due to illegal abortion. They also assumed that patients of criminal abortionists would have a higher mortality than would those of gynaecologists who were doing legal abortions. This argument gained little support outside the 25 people at the council
meeting. Because abortion was the most important single cause of maternal death, the Family Planning Association held a conference, chaired by Lord Brain, in April, 1966.3 Here Prof Philip Rhodes estimated from his own experience that there were about 86 000 criminal abortions per year in England and Wales but added "For the sake of argument I shall take the figure of 100 000 which has come to be widely accepted". Rhodes also demonstrated that illegal abortion was only about twice as dangerous as full-term pregnancy-far below the RCOG estimate. Thus, the sudden large increase in legal abortions in 1969 would have reduced livebirths substantially had it not followed an equally large number of illegal abortions, before that date. It is
important to remember that there were a large number of illegal abortions, but because of the great success of the 1967 Act criminal abortion has been virtually eliminated and maternal mortality has been strikingly reduced. We must accept that considerable numbers of therapeutic abortions will still be needed until contraception is more widely accepted and efficiently used. 10 Campden Hill Square, London W8 7LB, UK
PETER DIGGORY
Legalised abortion: a report by the Council of the Royal College of Obstetricians and Gynaecologists. Br Med J 1966; i: 850-54. 2. Chesser E. Cited by M. Pearson. Sunday Telegraph Jan 30, 1966, p 25. 3. Abortion in Britain. Proceedings of a conference held by the Family Planning Association on April 22, 1966. London: Pitman Medical, 1966. 1.
Clinical trials in
paediatrics
SIR, Medical Letter has lately published a note on sudden deaths at least three children treated with a tricyclic antidepressant (desipramine) and with plasma concentrations below the toxic ranged Children may be more susceptible than adults to cardiac toxicity from these drugs because of differences in pharmacokinetics. In our general hospital, with 585 beds, an annual average total of thirty-four projects for clinical trials comes before the ethics committee for approval. Only two are studies in children, and no study has been for a phase I clinical trial in children. Responsiveness to drugs is altered in children, mainly due to pharmacokineticsNevertheless it is commonly held that clinical
in
Abortion SIR,-When considering the possible consequences of permissive legislation on euthanasia Dr Twycross (Sept 29, p 796) referred to the increase in social abortion that followed the 1967 Abortion Act. Mr Diggory (Oct 20, p 1013), somewhat illogically, dismisses this concern with the statement that the principal aim of the Abortion Bill "was to reduce the very large number of criminal abortions then being done" and he cites 100 000 per annum in England and Wales as the estimate of the then Home Secretary. In 1966, the Council of the Royal College of Obstetricians and Gynaecologists, in its report on legalised abortion, considered the relevant reports on confidential inquiries into maternal deaths in England and Wales and the hospital inpatient inquiry and concluded that the number of criminal abortions in England and Wales, including those induced by women themselves, was less than 15 000 per annum. It is remarkable that 23 years on, with the annual abortion figure approaching 200 000, Diggory should quote a politician’s estimate rather than that of the Council of his own College to justify the 1967 Abortion Act. If euthanasia is being practised illegally in this country it would be disingenuous to suppose that its legalisation could not be followed by the same order of escalation as has occurred with abortion. 24 St Brannocks Road, Chorlton, Manchester M21 1UP, UK
*t* This
letter has been shown
JOHN MCLEAN to
Mr
Diggory,
whose
reply
follows.-ED. L.
SIR,—Why did I quote the Home Secretary’s estimate and omit that made by the Council of the Royal College of Obstetricians?1 The Home Secretary had access to large numbers of estimates by
trials in children should not be done for ethical reasons. As a result paediatricians use doses extrapolated from data on adults. More clinical trials should be done in paediatrics, to avoid risks when treating children with drugs. Clinical
Pharmacology Service, Hospital Germans Trias i Pujol, Autonomous University of Barcelona, Badalune (Barcelona), Spain
P. SALVA M. A. AGUADO
1. Anon. Sudden death in children treated with a tricyclic anti-depressant. Med Lett Drugs Ther 1990; 32: 53. 2. Robinson DS, Barker E. Tncyclic antidepressant cardiotoxicity. JAMA 1987; 236: 2089-90.
Rhabdomyolysis and temperature SIR,-Dr Cook and colleagues (Nov 3, p 1136) report nontraumatic rhabdomyolysis in a 37-year-old man, which they attribute to radiant heating (sunlight shining through glass shop windows) and convective heating (contact with air heated by sunlight). Our experience of over 700 clinical whole-body hyperthermia treatments suggests that it is unlikely that radiant and convective heating could account for this man’s rhabdomyolysis. We routinely heat cancer patients to a body core temperature of
