882

were delivered vaginally. There was 1 multiple pregnancy.There were no cases of prolonged labour.

Before delivery all patients had a positive H.I. test result atdilutions of up to 1 in 160 of urine. In 7 patients the H.I. testwas positive only to dilutions of 1 in 20 and 1 in 40. Of the

remaining 3 patients the test was positive to dilutions of 1 in160 in 1 patient and 1 in 80 in 2. Not a single patient had apositive H.I. test on or after the seventh day post partum. 9

patients had a negative H.I. test on the sixth day and 1 on theseventh day. The patient with a multiple pregnancy had anegative H.I. test from the third day post partum.

Shuttleworth found that the H.I. test became negativeon the seventh to tenth day after delivery. Althoughthe present series is not large, our findings suggest thatthe H.I. test in Johannesburg becomes negative before theseventh day post partum.

W. M. POLITZERH. GLIETENBERG.

South African Institutefor Medical Research,

Johannesburg.

BUCCAL OXYTOCIN

SYLVESTER KRZANIAK.Central Middlesex Hospital,

London, N.W.10.

SiR,-The articles by Dr. Spence and Dr. Chalmers andDr. Blair (March 21) prompt me to compare the resultswith my series of 231 cases with an average success of

62-5%.The clinical trial was carried out in two stages; the first group

of 166 patients showed that the use of buccal oxytocin(’ Pitocin ’) beyond two courses was impracticable. The resultswere as follows:

3 patients had buccal oxytocin for five or more days, and inall it was unsuccessful.

In the second group (65 patients), in whom the administra-tion of oxytocin was restricted to two courses, the success-ratewas 61% (only 3% less than in the first group).The follow-up of the patients who failed to go into labour

yielded valuable information. Of the 26 unsuccessful inductionsin the second group, 6 patients were given oxytocin in prepara-tion for surgical induction, when delivery was not reallyexpected. 3 responded to artificial rupture of membranes(A.R.M.); 1 refused A.R.M.; 1, still not suitable for A.R.M.,responded to three (twelve-hourly) intravenous infusions; andin 1 elderly primigravida with an unstable lie, delivery waseffected by cxsarean section. A further 6 patients had only onecourse for various reasons: 1 patient went into labour shortlyafter completion of the buccal course; 1 responded to A.R.M.;2 delivered after one intravenous oxytocin drip; and 2 hadabdominal deliveries (1 due to placenta prtvia, and 1 due to thefailure of three oxytocin drips before, and one after, buccaloxytocin).The remaining 14 patients had two unsuccessful courses of

buccal hormone. 4 responded to A.R.M. (of these, 1 neededmanual removal of the placenta). 2 had caesarean sections (1 onaccount of disproportion, and 1 because three oxytocin dripswere unsuccessful). 4 responded to intravenous oxytocin (2 toone drip; 1 to two drips; and 1 to three drips). 3 of these casesneeded forceps delivery owing to uterine inertia. In 2 patientsintravenous induction was followed by A.R.M., and when thisfailed a further intravenous drip followed. Both patients haduterine inertia and needed forceps delivery. 1 patient withdoubtful expected date of delivery was delivered naturally twoweeks later after A.R.M., and the last patient, with hydramnios,went into labour spontaneously three days after a failed buccalinduction.

It is tempting to conclude that when two courses of buccaloxytocin fail, this can be taken as a warning of some underlyingobstetric problem.

In certain circumstances the outcome of buccal inductionis more favourable than in others. Dr. Spence suggested that

1. Shuttleworth, E. M. Lancet, 1963, ii, 699.

ruptured membranes increase the success of buccal inductions.This is borne out by my figures, which also show that this isirrespective of the membranes being ruptured spontaneouslyor artificially:

Dr. Spence suggested that the period of gestation andthe proportion of successes were not related. In myexperience, induction was most successful at about40 weeks of gestation, which is in keeping with Dr.Blair’s findings.

POSTOPERATIVE PAIN

W. EDWARDS.

SIR,-In the past three years I have undergone a

prostatectomy and a hoemorrhoidectomy, and perhaps Ican offer some personal views on postoperative pain. Itis admittedly difficulty to judge a patient’s pain, but onecan be fairly sure about one’s own.

I found that the pain after prostatectomy was caused chieflyby the pressure of the balloon of a Foley catheter on the rawarea: it was quite severe, but lasted only till the cathether cameout on the fifth day. I can see no reason for withholding pain-killing drugs for such a short time.The pain after hamorrhoidectomy lasted more than a

month and was really severe. The amount of pethidine Iconsidered necessary was agreed to by my doctors, but ratherappalled my nurses, who clearly feared addiction; so, on oneoccasion, I received an injection of saline solution instead.There is no difficulty in distinguishing the effect. I had a

great deal of pethidine, but the moment the pain stopped, Istopped the drug, and had no desire at all for more. I doubtwhether a person who is not tempted to addiction can becomean addict in this way.

I have always felt that one’s duty as a doctor is to

relieve pain by all possible means. I think it is too easyto disregard a patient’s pain, to think he " shouldn’thave all these drugs ". If an experienced doctor cannottell when a patient is really in pain, his powers of obser-vatinn orf nrpttv nnnr

Ashtead,Surrey.

MEGALOBLASTIC ANÆMIA AND

NITROFURANTOIN

SIR,-Bass 1 reported megaloblastic anemia in a

patient with chronic urinary-tract infection who, over aperiod of nine months, had received three therapeuticcourses of nitrofurantoin (’ Furadantin’). He con-

cluded on the basis of this case that the drug produced afolic-acid deficiency with resultant anaemia. This con-clusion he supports by the false premise that nitro-furantoin is chemically related to phenytoin, which hasbeen implicated in the development of this type ofanaemia.

If a drug given in a relatively short course can interferewith folic-acid metabolism to the extent of producing overtmegaloblastic anxmia, it most probably functions as a potentfolic-acid antagonist-e.g., like methotrexate or pyrimetha-mine, which produce megaloblastic changes with regularity.On this hypothesis it should be possible to detect the bio-chemical effects of the drug in suitable patients. Serum" folate " (Lactobacillus casei) levels were measured at our

request by Dr. 1. Chanarin, of the M.R.C. ExperimentalHxmatological Research Unit, in a series of patients withurinary-tract infections before and after treatment with 200mg. of nitrofurantoin daily for eight days. Ten patients were

1. Bass, B. H. Lancet, 1963, i, 530.