A reader has written to us about young women who smoke, as some of her in-laws do. She worries because, although they don’t smoke in the presence of young children, the women may not even stop smoking when pregnant.
Few women could live in health-conscious Britain and not be aware that even the most hardened smokers accept the dangers of smoking when pregnant. Even before conception a would-be father’s potency and fertility is reduced. A woman’s rate of miscarriage is increased by 25 per cent if she smokes. Smoking also damages the placenta in later pregnancy. It is easy to understand the pharmacological reasons why arterial changes are associated with smoking and induce placental damage and high blood pressure, which results in a reduction in the birth weight of the baby and an increased risk of its death during delivery. The death rate in the babies of women who smoke at or around delivery is twice as high as it is in babies of non-smokers.
It is more difficult to understand why smoking also causes an increased rate of placenta praevia, the condition in which the placenta is implanted over the outlet of the womb. As pregnancy advances, the usual changes in the lower segment of the uterus may induce placental separation and bleeding that is sometimes a deluge. Naturally, if the placenta is covering the outlet of the uterus, vaginal delivery is impossible.
The problems of low birth weight are not over once a small baby born to a smoking mother is safely delivered. In the cot, a baby of low birth weight settles less readily and is more restless than its larger contemporaries. When at school, not all small babies of smoking mothers have caught up, and they may still be shorter and smaller and, it is suggested, sometimes less bright. The disadvantages of being small at birth don’t disappear, but they may remain hidden in early adult life.
However, in middle and old age, low birth weight again becomes important as it is one of the risk factors for cardiovascular disease, including heart attacks and strokes. Smoking around the house can increase the incidence of sudden cot death in children. This danger is greater than in non-smoking households whether the smoker is the mother or father.
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Our reader bravely wrote that she has the intention of changing the habits of her family’s younger generation. Parents may sometimes be forgiven for attempting, usually without success, to alter the habits of their own grown-up children. However, although I know of some in-laws who give advice successfully, it is usually the family equivalent of an invitation to pistols at dawn if an older generation, related only by marriage, tries to interfere with the lifestyle of younger family members and the bringing up of their children.
An octogenarian married woman has written to us asking for any advice about gallstone treatment. She mentions that a niece has had gallstones, and claims to have rid herself of them by drinking apple juice. Do I think this likely?
Twenty per cent of people over the age of 65 have gallstones, the great majority of which don’t cause symptoms and should be ignored, provided that the diagnosis is foolproof. Gallstones may certainly cause transient biliary colic when a stone is passing, or attempting to pass, down the bile duct. The pain, of variable intensity, passes off within hours but may be accompanied by nausea and vomiting. The pain, more likely to be induced by the size and richness of a meal than its fat content, is felt maximally in the upper right-hand section of the abdomen.
Gallstones may cause complications other than pain, including inflammation of the gall bladder (cholecystitis) or infection of the gall bladder (cholangitis). Cholecystitis causes pain in about the same area as simple gallstones, but may radiate to the shoulder, lasts longer, and is accompanied by tenderness and, frequently, a temperature.
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If the gallstones are giving rise to complications, the usual treatment is initially conservative, with surgery later. Surgery is the treatment of choice if the pain of gallstones is causing recurrent trouble. Traditionally, the abdomen was opened with a wide incision, but now keyhole surgery using laparascopic techniques is often preferred. About 5 per cent of cases that started with laparascopic procedures end by having open surgery.
The advantages of laparascopic surgery include a shorter hospital stay with less risk of infection and a smaller, quicker-healing scar with less post-operative discomfort. Keyhole surgery has no greater complication rate than open surgery. Although octogenarians without pain or complications should be treated conservatively, people with diabetes are usually recommended to have surgery for gallstones. Other complications include perforation of the gall bladder and pancreatitis.
I suspect that the taking of apple juice by the reader’s niece coincided with a period of remission of gall bladder symptoms, as happens in up to 40 per cent of people with gallstones. Neither Culpepper’s early 19th-century herbal, nor the 21st-century medical guide to herbalism, mentions apples for treating gallstones. Some herbalists recommend olive oil. But the standard way of dissolving gallstones is not with either apple juice or olive oil but with oral bile acids such as ursodeoxycholic. Unfortunately, these have to be taken for months and months and even then 50 per cent recur within five years.
The other risk factors developing gallstones used to be summed up, doctors now believe too simplistically, as affecting patients who are fair, fat, female and 50 (some say 40). In all adults, raised cholesterol and diabetes are possible factors.
Gallstone formation may be encouraged by lengthy or repeated surgery, especially that for such conditions as burns or those involving sepsis. Gallstones are more likely if the patient has been drip-fed for any length of time.
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