Abortion and the search for public policy.

PIP: The social policy towards abortion determined by the Roe vs. Wade decision can be overturned at any time depending upon how the US Supreme Court reacts to challenges to its earlier ruling. Roe vs. Wade was decided by a 7 to 2 vote, and the members of the Supreme Court appointed by Presidents Reagan and Bush were chosen to uphold a conservative (anti-abortion) ideology. Although more than half of the present Court was appointed by these presidents, President Clinton now has the opportunity to appoint 2 more Justices. The public policy positions which are currently available to the Supreme Court or to Congress can be ranked on a chart from liberal to conservative. In this article, 7 different positions are described in detail, and the public policy implications of the implementation of each position are described. The first position considered is the extreme conservative position of "no abortion; no exceptions" as defined by author and Roman Catholic theologian Gerald Kelly. The only procedures allowed which would end the life of a fetus would be those to remove an ovary or fallopian tube in the case of an extrauterine pregnancy (permissible under the doctrine of double effect). In the most extreme interpretation of this situation (which Kelly does not seem to hold), those who perform abortions would be prosecuted for murder. The next position considered is the most liberal position, which is espoused by Michael Tooley, and which holds that abortion and early infanticide are both permissible. The third position is that which allows no abortion but has limited exceptions in cases of rape or incest. The appropriate consideration for abortion presented next is that of the late Joseph Fletcher who believed that whatever love requires is the proper response to the situation. Philosopher Dan Callahan espouses the notion that abortion should be performed for compelling reasons only (after effective counseling). The trimester approach to the problem of abortion is that set forth by Justice Harry Blackmun in Roe vs. Wade. This approach gives a woman freedom to decide to have an abortion during the first 2 trimesters of her pregnancy only. This approach has essentially dictated public policy in the US since 1973. The last position considered is that which maintains that a woman's right to equality demands that she have sole control over whether or not to have an abortion.^ieng

Choice of emergency operative procedure for bleeding duodenal ulcer.

In a consecutive series of 201 emergency operations in patients with bleeding duodenal ulcer the size of the ulcer was the only factor that showed a significant correlation with the procedure chosen. Vagotomy, pyloroplasty and underrunning of the bleeding point was performed in 101 cases with ten deaths (10 per cent), partial (Billroth II) gastrectomy in 81 cases with ten deaths (12 per cent), and vagotomy and antrectomy in 16 cases with one death (6 per cent). A patient was more likely to be treated by partial gastrectomy if a giant ulcer with an internal diameter of greater than or equal to 2 cm was found. The results suggest that while vagotomy and pyloroplasty, combined with a direct attack on the bleeding point or excision of an anterior ulcer is an acceptable standard emergency operation for bleeding duodenal ulcer, gastric resection proved to be a satisfactory alternative procedure and should be considered in the technically difficult case with a very large ulcer. A giant ulcer was present in 37 per cent of cases coming to surgery.

The natural history of peptic oesophageal strictures treated by dilatation and antireflux therapy alone.

A total of 195 patients with benign peptic oesophageal strictures treated by endoscopic dilatation and antireflux medication between July 1977 and July 1986 were studied prospectively to determine the effect of such treatment on the subsequent course of this disease. Of the patients, 58% were female and they were significantly older than the males at the time of initial presentation (75 years vs 68 years, P less than 0.0001). 46% of both sexes required only one dilatation but the men required more dilatations over a longer period: 31% males vs 19% females required more than 3 dilatations (P less than 0.05) and 40% males vs 27% females were being dilated 2 years or more after the initial dilatation (P less than 0.05). Dilatation combined with antireflux medication is clearly an effective method of management for most patients with peptic oesophageal strictures. The value of antireflux surgery requires evaluation for that subset of patients, predominantly males, who require long-term and repeated dilatation.

Collagenous colitis: a recently recognised reversible clinicopathological entity.

A case of collagenous colitis is reported in an 86 year old man who presented with watery diarrhea. This case differs from previous reports in that five of the six reported cases involved women, mostly in their mid-forties, and that previously the collagenous band has been demonstrated in the mucosa of the left side of the colon only. This case is the first report to demonstrate the collagenous band in the right side of the colon as well as the left, and is the thickest band reported to date. In keeping with the two reported cases with follow-up, the subepithelial collagenous band was shown to have disappeared three months after the initial biopsy with a corresponding clinical improvement after symptomatic treatment only. The diagnosis needs to be considered in all patients presenting with watery diarrhea, and can only be confirmed after rectal or colonic biopsy.

Colonoscopic polypectomy in a regional teaching hospital.

Five hundred and thirty-five polyps were found in 200 patients over 6 years at a regional teaching hospital. Eighty-five per cent of the patients were from the hospital area yet the presentation of the patients, the complications of polypectomy, the size, distribution and histological features of the polyps were similar to large series reported from metropolitan specialist centres of referral both in this country and the USA. However, a smaller proportion of our polyps were over 1 cm diameter. Between 25 and 53 per cent of patients had recurrent or residual polyps on the second and third colonoscopy. Patients with two or more polyps at the first endoscopy were significantly more likely (P less than 0.01) to have further polyps at follow-up. We therefore recommend that patients with colonic polyps are colonoscoped annually until free from polyps for 2 years, before being placed on colonoscopic review at 5-year intervals.

Histological study of the effects of three anti-inflammatory preparations on the gastric mucosa.

Patients with osteoarthritis were entered into a single-blind trial comparing the effects on the gastric mucosa of a four week course of indomethacin, sulindac and a compound of paracetamol and dextropropoxyphene (Distalgesic). The presence and severity of both acute and chronic gastritis were assessed by histological examination of endoscopic biopsy specimens taken from five standard sites in th stomach of each patient before and at the end of the four week period. The presence and severity of chronic gastritis was not affected by the treatment in any of the groups. The pattern of acute gastritis was complex, many of the patients having acute inflammatory changes in their initial biopsy specimens. At least one patient in each treatment group developed marked acute gastritis during the treatment period, but a significant overall increase in the severity of these changes was only found in the group treated with sulindac.

Length measurement by means of a grid.

Experiments were performed which demonstrate some of the length-measuring characteristics of a grid consisting of two sets of parallel lines crossing each other at right angles. If lines of various shapes are repeatedly superimposed at random on such a grid, the mean number of intersections each of these lines makes with the lines of the grid is directly proportional to the length of the line. There is a property of two-dimensional curves, which may be called directional bias, the presence of which in a test curve will increase the variability of the number of intersections made with the grid lines and skew the frequency distribution curve to the right. This effect is markedly reduced by taking the mean of three measurements if the second and third are taken with the grid rotated 30 degrees and 60 degrees respectively from its original position in relation to the test curve. Information gained from these experiments can be applied to stereological problems such as the estimation of particle densities in histological sections.

A method for the quantification of human gastric G cell density in endoscopic biopsy specimens.

A previously described method for estimating G cell density in endoscopic biopsy specimens has been modified to take into account observations of the way in which specimens behave when they are deformed and some of the length-measuring characteristics of a grid used to measure the length of tissue profiles. The relationships between particle densities in sections and particle densities in tissue of which the sections are representative are discussed.