Letters to the Editor - Europe PMC

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The Ebers Papyrus contains many references to childbirth and the customs related to it. If labour is not going well the vulva is fumigated with a wax preparation.

Journal of the Royal Society of Medicine Volume 86 December 1993

Professor Chamberlain showed slides of pictures taken on his travels in Egypt, including a husband and wife exchanging a toasting-fork-like implement which represented the life force, Isis, sitting propped up in labour, the usual position for birth, and a limestone carving of 2500 BC which was possibly the first depiction of birth in the world. The Ebers Papyrus contains many references to childbirth and the customs related to it. If labour is not going well the vulva is fumigated with a wax preparation. Breast feeding was maintained for

Letters to the Editor Preference is given to the letters commenting on contributions published recently in the JRSM They should not exceed 300 words and should be typed double-spaced. Breast cancer and pregnancy In their excellent review of breast cancer and pregnancy (March 1993 JRSM, p 162), Mr Saunders and Professor Baum state that there is no evidence for any teratogenic effect of tamoxifen. Although it appears not to give rise to malformations easily recognizable at birth, tamoxifen therapy may not be entirely without risk to the fetus. Tamoxifen, a non-steroidal oestrogen with partial agonist activity, has close structural homology with diethylstilboestrol (DES). Exposure to DES in utero is well known to induce structural abnormalities of the genital tract ofboth male and female human fetuses1 which usually pass unrecognized at birth. In addition, DES exposure in utero predisposes to clear-cell adenocarcinoma of the vagina and cervix in adult life2. Although the vaginal stigmata have been identified in exposed daughters in whom DES was first administered after the twentieth week of pregnancy, the risk appears to decline with advancing gestational age at first exposure particularly after the end of the sixteenth week3. Using isolated fetal vaginae from aborted human fetuses in culture as a model for the effects of synthetic non-steroidal oestrogens on embryonic genital tissues, Cunha et al. found that incubation with tamoxifen induced histological changes almost identical to those produced by DES4. This

experimental model employed supra-pharmacological doses and the relevance of these data to the developing fetus is therefore unclear. Nevertheless, it would seem prudent to delay the commencement of therapy until the end of the sixteenth week (or after delivery whenever possible), and to advise women of this theoretical risk so appropriate followup of their daughters (and sons) can be arranged. ROBERT Fox

University Department of Obstetrics and Gynaecology St Michael's Hospital Southwell Street Bristol BS2 8EG, UK

References 1 Robboy SJ. Diethylstilboestrol exposure in human offspring. Studd J, ed. Progress in Obstetrics and Gynaecology, Vol 1. London: Churchill Livingstone, 1981 2 Herbst AL, Cole P, Norusis MJ, Welch WR, Scully RE. Ageincidence and risk of diethylstilboestrol-related clear cell adenocarcinoma of the vagina and cervix. Am J Obstet Gynecol 1977; 128:43-9 3 O'Brien PC, Noller KL, Robboy SJ, Barnes AB, Kaufman R, Tilley B, et al. Vaginal epithelial changes in young women enrolled in the national cooperative diethylstilboestrol adenosis (DESAD) project. Obstet Gynecol 1979;53:300-9 4 Cunha GR, Taguchi 0, Namiawa R, Fujii H. Teratogenic effects of clomiphene, tamoxifen and diethylstilboestrol on the developing human female genital tract. Human Pathol 1987;18:1132-43

several years after the birth and it was thought that sperm came from the man's heart. Mammesi referred to a birth room in the temples but probably only the goddesses were permitted to use the room for that purpose, although ordinary citizens may have received instruction in them. Various recipes for contraception were listed, many containing honey but, in extremis, crocodile excreta in sour milk would be used. M A Smith History of Medicine Section

The current debate concerning f-agonists in asthma I read with interest the article by Chung (February 1993 JRSM, pp 96-100) reviewing the current debate concerning ,-agonists in asthma. The article fails, however, to mention aspects of psychiatric morbidity associated with ,8-agonist inhalation and fails to discuss the possibility that subsequent morbidity could be related to the presence of flourinated hydrocarbon propellants present in the pressurized aerosols, rather than the active fl-agonist agent itself. Although significant psychiatric reactions are infrequent with ,B-agonists, awareness of their occurrence must exist among the caring professions. Salbutamol induced psychoses incorporating disturbed behaviour, hallucinations and persecutory delusions have been reported",2. Other effects include anxiety, restlessness, nervousness, tremor, irritability, insomnia and emotional lability. Psychological dependence without prominent psychiatric symptoms can also occur3. Salbutamol is reported to have antidepressant properties4 which may explain some of the psychiatric morbidity associated with the use of this group of drugs. A review of case reports of addiction to pressurized aerosols along with a discussion of the possible agents of addiction, has recently been described'. Of utmost importance is whether the fluorinated hydrocarbons in the pressurized aerosol containers can cause additional morbidity. The practice of aerosol inhalation, incorporating fluorinated hydrocarbons, was implicated in the report of 110 deaths described by Bass5. Hydrocarbons are absorbed into the blood after inhalation6, can sensitize the cardiac musculature to arrthymic effects of endogenous catacholamines7 and can cause a respiratory arrest8. I agree with the concern expressed by Chung about the indiscriminate use of fl-agonists in asthma. My comments relate to the associated psychiatric morbidity and to the possibility that fluorinated hydrocarbons rather than the active fl-agonist could cause the wide spectrum of morbidity reported. V P PRASHER

Department of Psychiatry University of Birmingham

Birmingham B15 2QZ, UK References 1 Prasher VP, Corbett JA. Aerosol addiction. Brit J Psychiat 1990;157:922-4 2 Gluckman L. Ventolin Psychosis. NZ Med J 1974;80:411 3 Pratt HF. Abuse of salbutamol inhalers in young people. Clin Allergy 1982;12:203-9 4 Widlocher D, Lecrubier Y, Jouvent R, Puech AJ, Simon P. Antidepressant effect of salbutamol. Lancet 19771i:767 5 Bass M. Sudden sniffing death. J Amer Med Assoc 1970;212:2075 6 Dollery CT, Draffan GH, Davies DS, Williams SM, Conolly ME. Blood concentrations in man of fluorinated hydrocarbons after inhalation of pressurised aerosols. Lancet 1970;ii:1164-6 7 Boon NA. Solvent abuse and the heart. BMJ 1987;294:722 8 Cronk SL, Barkley DEW, Farrell MF. Respiratory arrest after solvent abuse. BMJ 1985;290:897

The author replies below Dr Prasher raises the possibility that fluorinated hydrocarbon propellants in pressurized aerosols may be reponsible