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FOLLOW-UP AFTER STERILISATION
1315 FOLLOW-UP AFTER STERILISATION
From this evidence and from my findings of the characteristic
ultrastructural and enzymic changes which I have reportedI1 should like to propose that in the future we consider malignant melanoma to be not one but two diseases: melanocytic malignant melanoma or malignant melanocytoma; and nasvocytic malignant melanoma or malignant naevocytoma. The differences in malignancy, radiosensitivity, and prognosis, together with differences in biological behaviour, may be explained by the separate ontogenies of these two conditions which I have summarised in the accompanying schema. Here we can see that the neural crest differentiates into melanoblasts, and further into melanocytes, which can undergo initial neoplastic changes, resulting in lentigo senilis. Lentigo senilis can further undergo premalignant changes, becoming Dubreuilh’s precancerous melanosis, which generally undergoes malignant changes, becoming malignant melanocytoma. The neural crest can also differentiate to the bipotential naevoblast, which can then become lentigo simplex, leading further to junction nasvus. Junction nxvi can occasionally undergo malignant changes resulting in the highly invasive malignant nxvocytoma. Department of Dermatology, Wakayama Medical University, YUTAKA MISHIMA. Wakayama-shi, Japan.
EARLY DISCHARGE AFTER HERNIA REPAIR
SiR,ńThe letter by to
Mr.
Perry (May 4,
p.
975) prompts
me
write.
I was operated on for a right indirect hernia under local anxsthesia by my friend, Mr. J. R. McCorriston, in the General Hospital, Kingston, Ontario, on Feb. 26, 1968. At my own insistence I was discharged twenty-four hours later. I returned to my home by train (120 miles) and I continued my duties at this sanatorium and two general hospitals as a consultant thoracic surgeon without much interruption. For 3 days I took’Fiorinal’ (Sandoz), about two tablets, q.i.d., and for another week I took aspirin occasionally. From my experience as a patient I am for local anxsthesia, and for very early discharge after surgery. St. Lawrence Sanatorium, Z. GORECKI. Cornwall, Ontario.
THE COOMBS TEST AND METHYLDOPA SIR,-We have read with interest the letters of Dr. Seedat and Dr. Vawda (Feb. 24, p. 427) and Dr. Breckenridge and his colleagues (March 9, p. 533). In our recent study3 on this subject we too failed to detect any positive direct Coombs tests (D.C.T.S) in 80 hypertensive African patients treated with methyldopa. We felt, however, that this may, in part, have been due to the fact that the African hypertensives had generally required lower dosages of the drug than had the White and Coloured hypertensives in our series. We also suspected that many were not taking their tablets regularly. Of the 70 Coloured patients, 4 (7%) had positive D.C.T.s and 1 of these was an Indian male-this in a group which contained few Indian patients. Furthermore, it was recently brought to our attention (personal communication from Dr. F. Segal) that an African patient treated for hypertension at Baragwanath Hospital, with methyldopa, developed a positive D.c.T. with hoemolytic ansemia. We therefore agree with Dr. Breckenridge and his colleagues that positive D.c.T.s do occur in persons of nonEuropean stock treated with methyldopa. African patients appear to be less prone to the hazard, but this point requires further evaluation. Coronation Hospital, South African Institute B. I. JOFFE for Medical Research, I. SPECTOR. Johannesburg. Mishima, Y. in Advances in Biology of Skin; vol. VIII. The Pigmentary System. New York, 1967. 3. Spector, I., Joffe, B. I., Zoutendyk, A., Fraser, B., Spitz, I. M., Dubb, A., Kew, M. D., Jones, G. C., Hart, D. S. Afr. med. J. 1968, 42, 339. 2.
SIR,-Iread with interest the article by Dr. Thompson and Sir Dugald Baird (May 11, p. 1023). A colleague and I, both professional social workers, employed by a local authority, carried out a survey of 16 cases of sterilisation in families of the lowest income group, the husbands being unemployed, or either employed spasmodically or as unskilled labourers. All the families were well known to social agencies and all but two had had serious family problems before any action had been taken to discuss or advise sterilisation. In these cases there seems to have been little personal preparation of the wives, and, to a greater extent, of the husbands, and the results, though successful in one direction, often have by no means been as full, or as long lasting, as had been hoped. Most of the husbands and wives had had unhappy childhood experiences. They seemed to have few expectations from life and envisaged little more from their marriage, or their children, than had been their own parents’ lot. They had no particular aspirations for themselves or for their children, nor did they expect, or desire, to move up the social scale in any way. Marriage seemed based on the physical relationship and this remained of paramount importance. As the families grew, so did the concern of the family doctors and social workers trying to maintain them. Attempts were made in most cases to encourage the use of contraceptives, but these
failed, mainly owing to non-cooperation and, to some extent perhaps, to ineffective counselling. In most cases, after the operation had been carried out, the parents seemed to enjoy a honeymoon period, which was fairly quickly followed by rapid deterioration in the marital situation, often ending in complete break-up. Husbands and wives regretted the operation and attributed most of their developing problems to it. They seemed to be people for whom pregnancy, or the ability to procreate, had a special significancethat having children was the one sure way in which they could prove themselves, and to others, that they were complete people. If this ability was removed, with little else to put in its place, or without being given assistance to accept the situation, then the mainspring of the marriage could be broken. One case was that of a couple who married when the wife was very young. Both came from unhappy backgrounds, and the main reason for the marriage was that she was pregnant. The wife expected to spend the rest of her life within the home. She had spent the very short time between leaving school and getting married working in a laundry, and did not particularly want to return to that kind of work, or, indeed, to any work outside the home. During the first three or four years of marriage, three children were born to them. When a fourth pregnancy followed rather swiftly their doctor suggested that they might, with advantage, space their family out a little better. The husband refused completely to take any responsibility for this himself, saying that it was " unnatural " and that it would spoil his pleasure. The wife, while complaining bitterly of her husband’s demands and saying that she did not want any more children, nevertheless refused appointments made for her at the local family planning clinic, on the grounds that she did not want to be messed about ". More pregnancies followed in quick succession. The wife’s health began to suffer, and she complained that her husband did not give her sufficient support, and that he was usually to be found in the local public-house each evening. She found it difficult financially, "
and there was a time when the rent began to get into arrears. A threat of eviction was staved off. Their doctor then prescribed an oral contraceptive, but the wife almost immediately complained that it did not suit her, and discontinued taking it after three weeks. The following month she became pregnant
again. The wife was now aged twenty-eight, and when the child born she had had eleven pregnancies altogether, resulting in seven live births. Considerable pressure was exerted on the couple to agree to the wife undergoing a sterilisation operation, and eventually they agreed. The operation was performed while she was in hospital after the birth of the last was
1316 child. Her husband, who had been the more reluctant of the two to give consent to the operation, still seemed a little unsure of his feelings while she was in hospital, but on her the couple appeared to enter a honeymoon period. However, within three months, marital discord had become serious, and the husband had started to beat his wife with
return
frequency, often after drinking bouts. Later that year, with very little warning, the wife deserted the family and the younger children were received into the care of the local authority. The older ones were looked after by the husband, who was given a limited leave of absence from his employment for this purpose. It was learned that the wife had gone to her mother. When the weeks passed with no sign of her returning, the husband’s employers terminated his contract. Both husband and wife were seen by the social worker during this period. The wife said that she felt a sense of failure because of her inability to conceive, and thought her life would be empty and meaningless in the future when her seven children were not so dependent on her. She complained of various physical disabilities, such as menstrual irregularity, and pain or bleeding when intercourse was attempted, for which there seemed to be no medical reason. The husband said he looked back on the times when his wife had been pregnant as the happiest of the marriage, and she confirmed this opinion. He expressed the feeling that, because of the operation, his wife was no longer a " real woman ", but several times he told the social worker that he was prepared to have his wife back, and to forgive her, even though she was " no good to any man now ". At the same time he began to look around for a substitute and advertised for a housekeeper. There are in such situations a number of other possible difficulties that a couple may have had to face, over and above the ones they were able to relate. It seems that for some, the excitement, purpose, and pleasure of sexual relations is much diminished if there is no possibility of impregnation. Some husbands felt that their wives could now be unfaithful with impunity and an element of jealousy became very apparent. More than one husband accused his wife of sexual relations with all the men who called at the house. One of the results noted in Family Failureis that about 50% of the men investigated had little or no network of friends or social contacts, and this applied to some of the husbands of the group described here. This could be the reason why, in three cases, a charge of incest resulted. One man had two children by his first wife, then separated and cohabited with a divorcee with four children. After divorce he married his cohabitee and had six children over seven and a half years. After the birth of the last child the wife underwent sterilisation. Soon afterwards the eldest stepdaughter began to complain of difficulties in her relations with her stepfather and she was discovered to be pregnant. The stepfather was accused of offences not only with the eldest stepdaughter but also with the youngest, who later gave details of molestation accompanied by bribes and threats, which had started at about the same time as her sister’s experiences. Some eighteen months after his wife’s sterilisation he was sentenced to three years’ imprisonment. Some other unforeseen results occur. One mother, after having had five children, was sterilised in the hope that her somewhat shaky marriage might be improved. She had been brought up as a Roman Catholic, although in adult life she had abandoned this faith to become an occasional attender at Church of England services, and had brought up her children as Anglicans. She had given no thought to the possibility of feelings of guilt which nevertheless followed her operation. Some two or three years later her eldest daughter became pregnant when aged sixteen, and it seemed that the mother had encouraged the girl to become so. Against the wishes of her husband, she insisted that her daughter bring the baby home. She then became busily engaged in helping to care for this child exclusively. She thus appeared to satisfy her need through her daughter. some
1.
Philp,
A. F.
Family Failure. London,
1963.
The families investigated had an impoverished background and poor personality nourishment, and consequently many difficulties to face. They could easily find the operation to be a convenient and welcome peg upon which to hang all the blame for their problems. These considerations indicate the need for very guarded action as far as sterilisation is concerned. With such a small number of cases it is not possible to reach any conclusion, though my colleagues and I should have liked to follow up the possibility of some connection between sterilisation and incest. We felt that sterilisation in these cases seemed to put further strain on the unity of families which social workers were striving to maintain. Possibly better and more efficient counselling on the use of contraceptives would be the best approach with this type of family, since this would not lead to the loss of the ability to conceive. Parkstone, Poole, Dorset. JAMES R. LAUGHARNE. A SELF-ADJUSTING CHIN-SUPPORT
SIR,-Respiratory obstruction in non-intubated ansesthetised unconscious patients can usually be prevented by using an oropharyngeal airway and holding the mandible upwards and forwards. A satisfactory support for the chin which leaves the hands free has been devised with a simple quoit. This is a ring of ’Sorbo ’ sponge rubber, 17 cm. in diameter, used for playing quoits or deck-tennis. The patient, asleep and with slack neck muscles, is positioned with the head slightly rotated. The quoit is then compressed so that it slips in between the mandible and clavicle. Adjusting itself to the length of the neck the ring adopts an oval shape and its natural resilience thrusts the chin upwards (see figure). The position of the or
Sorbo
quoit
in
position
as a
chin-support.
the clavicle may be varied according to the shape and dimensions of the neck. In some individuals it sits snugly between the root of the neck and the clavicle. In others it rests on the junction of the middle and outer third of the bone above the deltopectoral triangle. A thin layer of clothing or a theatre-gown gives the quoit a better grip in the latter position. Respiration must be observed as always. This device has been used for patients from the age of 7 years upwards, having neck circumferences ranging from 23 to 44 cm. (9-171/2 in.), with related variations in length. In all cases a completely satisfactory airway has been maintained without any further attention.
quoit on
The sorbo quoit 3s. 9d.
can
be obtained from sports
Department of Anæsthetics, General Hospital, Newcastle upon Tyne NE4 6BE.
outfitters, and
co;ts
L. J. DUNKIN.
From this evidence and from my findings of the characteristic
ultrastructural and enzymic changes which I have reportedI1 should like to propose that in the future we consider malignant melanoma to be not one but two diseases: melanocytic malignant melanoma or malignant melanocytoma; and nasvocytic malignant melanoma or malignant naevocytoma. The differences in malignancy, radiosensitivity, and prognosis, together with differences in biological behaviour, may be explained by the separate ontogenies of these two conditions which I have summarised in the accompanying schema. Here we can see that the neural crest differentiates into melanoblasts, and further into melanocytes, which can undergo initial neoplastic changes, resulting in lentigo senilis. Lentigo senilis can further undergo premalignant changes, becoming Dubreuilh’s precancerous melanosis, which generally undergoes malignant changes, becoming malignant melanocytoma. The neural crest can also differentiate to the bipotential naevoblast, which can then become lentigo simplex, leading further to junction nasvus. Junction nxvi can occasionally undergo malignant changes resulting in the highly invasive malignant nxvocytoma. Department of Dermatology, Wakayama Medical University, YUTAKA MISHIMA. Wakayama-shi, Japan.
EARLY DISCHARGE AFTER HERNIA REPAIR
SiR,ńThe letter by to
Mr.
Perry (May 4,
p.
975) prompts
me
write.
I was operated on for a right indirect hernia under local anxsthesia by my friend, Mr. J. R. McCorriston, in the General Hospital, Kingston, Ontario, on Feb. 26, 1968. At my own insistence I was discharged twenty-four hours later. I returned to my home by train (120 miles) and I continued my duties at this sanatorium and two general hospitals as a consultant thoracic surgeon without much interruption. For 3 days I took’Fiorinal’ (Sandoz), about two tablets, q.i.d., and for another week I took aspirin occasionally. From my experience as a patient I am for local anxsthesia, and for very early discharge after surgery. St. Lawrence Sanatorium, Z. GORECKI. Cornwall, Ontario.
THE COOMBS TEST AND METHYLDOPA SIR,-We have read with interest the letters of Dr. Seedat and Dr. Vawda (Feb. 24, p. 427) and Dr. Breckenridge and his colleagues (March 9, p. 533). In our recent study3 on this subject we too failed to detect any positive direct Coombs tests (D.C.T.S) in 80 hypertensive African patients treated with methyldopa. We felt, however, that this may, in part, have been due to the fact that the African hypertensives had generally required lower dosages of the drug than had the White and Coloured hypertensives in our series. We also suspected that many were not taking their tablets regularly. Of the 70 Coloured patients, 4 (7%) had positive D.C.T.s and 1 of these was an Indian male-this in a group which contained few Indian patients. Furthermore, it was recently brought to our attention (personal communication from Dr. F. Segal) that an African patient treated for hypertension at Baragwanath Hospital, with methyldopa, developed a positive D.c.T. with hoemolytic ansemia. We therefore agree with Dr. Breckenridge and his colleagues that positive D.c.T.s do occur in persons of nonEuropean stock treated with methyldopa. African patients appear to be less prone to the hazard, but this point requires further evaluation. Coronation Hospital, South African Institute B. I. JOFFE for Medical Research, I. SPECTOR. Johannesburg. Mishima, Y. in Advances in Biology of Skin; vol. VIII. The Pigmentary System. New York, 1967. 3. Spector, I., Joffe, B. I., Zoutendyk, A., Fraser, B., Spitz, I. M., Dubb, A., Kew, M. D., Jones, G. C., Hart, D. S. Afr. med. J. 1968, 42, 339. 2.
SIR,-Iread with interest the article by Dr. Thompson and Sir Dugald Baird (May 11, p. 1023). A colleague and I, both professional social workers, employed by a local authority, carried out a survey of 16 cases of sterilisation in families of the lowest income group, the husbands being unemployed, or either employed spasmodically or as unskilled labourers. All the families were well known to social agencies and all but two had had serious family problems before any action had been taken to discuss or advise sterilisation. In these cases there seems to have been little personal preparation of the wives, and, to a greater extent, of the husbands, and the results, though successful in one direction, often have by no means been as full, or as long lasting, as had been hoped. Most of the husbands and wives had had unhappy childhood experiences. They seemed to have few expectations from life and envisaged little more from their marriage, or their children, than had been their own parents’ lot. They had no particular aspirations for themselves or for their children, nor did they expect, or desire, to move up the social scale in any way. Marriage seemed based on the physical relationship and this remained of paramount importance. As the families grew, so did the concern of the family doctors and social workers trying to maintain them. Attempts were made in most cases to encourage the use of contraceptives, but these
failed, mainly owing to non-cooperation and, to some extent perhaps, to ineffective counselling. In most cases, after the operation had been carried out, the parents seemed to enjoy a honeymoon period, which was fairly quickly followed by rapid deterioration in the marital situation, often ending in complete break-up. Husbands and wives regretted the operation and attributed most of their developing problems to it. They seemed to be people for whom pregnancy, or the ability to procreate, had a special significancethat having children was the one sure way in which they could prove themselves, and to others, that they were complete people. If this ability was removed, with little else to put in its place, or without being given assistance to accept the situation, then the mainspring of the marriage could be broken. One case was that of a couple who married when the wife was very young. Both came from unhappy backgrounds, and the main reason for the marriage was that she was pregnant. The wife expected to spend the rest of her life within the home. She had spent the very short time between leaving school and getting married working in a laundry, and did not particularly want to return to that kind of work, or, indeed, to any work outside the home. During the first three or four years of marriage, three children were born to them. When a fourth pregnancy followed rather swiftly their doctor suggested that they might, with advantage, space their family out a little better. The husband refused completely to take any responsibility for this himself, saying that it was " unnatural " and that it would spoil his pleasure. The wife, while complaining bitterly of her husband’s demands and saying that she did not want any more children, nevertheless refused appointments made for her at the local family planning clinic, on the grounds that she did not want to be messed about ". More pregnancies followed in quick succession. The wife’s health began to suffer, and she complained that her husband did not give her sufficient support, and that he was usually to be found in the local public-house each evening. She found it difficult financially, "
and there was a time when the rent began to get into arrears. A threat of eviction was staved off. Their doctor then prescribed an oral contraceptive, but the wife almost immediately complained that it did not suit her, and discontinued taking it after three weeks. The following month she became pregnant
again. The wife was now aged twenty-eight, and when the child born she had had eleven pregnancies altogether, resulting in seven live births. Considerable pressure was exerted on the couple to agree to the wife undergoing a sterilisation operation, and eventually they agreed. The operation was performed while she was in hospital after the birth of the last was
1316 child. Her husband, who had been the more reluctant of the two to give consent to the operation, still seemed a little unsure of his feelings while she was in hospital, but on her the couple appeared to enter a honeymoon period. However, within three months, marital discord had become serious, and the husband had started to beat his wife with
return
frequency, often after drinking bouts. Later that year, with very little warning, the wife deserted the family and the younger children were received into the care of the local authority. The older ones were looked after by the husband, who was given a limited leave of absence from his employment for this purpose. It was learned that the wife had gone to her mother. When the weeks passed with no sign of her returning, the husband’s employers terminated his contract. Both husband and wife were seen by the social worker during this period. The wife said that she felt a sense of failure because of her inability to conceive, and thought her life would be empty and meaningless in the future when her seven children were not so dependent on her. She complained of various physical disabilities, such as menstrual irregularity, and pain or bleeding when intercourse was attempted, for which there seemed to be no medical reason. The husband said he looked back on the times when his wife had been pregnant as the happiest of the marriage, and she confirmed this opinion. He expressed the feeling that, because of the operation, his wife was no longer a " real woman ", but several times he told the social worker that he was prepared to have his wife back, and to forgive her, even though she was " no good to any man now ". At the same time he began to look around for a substitute and advertised for a housekeeper. There are in such situations a number of other possible difficulties that a couple may have had to face, over and above the ones they were able to relate. It seems that for some, the excitement, purpose, and pleasure of sexual relations is much diminished if there is no possibility of impregnation. Some husbands felt that their wives could now be unfaithful with impunity and an element of jealousy became very apparent. More than one husband accused his wife of sexual relations with all the men who called at the house. One of the results noted in Family Failureis that about 50% of the men investigated had little or no network of friends or social contacts, and this applied to some of the husbands of the group described here. This could be the reason why, in three cases, a charge of incest resulted. One man had two children by his first wife, then separated and cohabited with a divorcee with four children. After divorce he married his cohabitee and had six children over seven and a half years. After the birth of the last child the wife underwent sterilisation. Soon afterwards the eldest stepdaughter began to complain of difficulties in her relations with her stepfather and she was discovered to be pregnant. The stepfather was accused of offences not only with the eldest stepdaughter but also with the youngest, who later gave details of molestation accompanied by bribes and threats, which had started at about the same time as her sister’s experiences. Some eighteen months after his wife’s sterilisation he was sentenced to three years’ imprisonment. Some other unforeseen results occur. One mother, after having had five children, was sterilised in the hope that her somewhat shaky marriage might be improved. She had been brought up as a Roman Catholic, although in adult life she had abandoned this faith to become an occasional attender at Church of England services, and had brought up her children as Anglicans. She had given no thought to the possibility of feelings of guilt which nevertheless followed her operation. Some two or three years later her eldest daughter became pregnant when aged sixteen, and it seemed that the mother had encouraged the girl to become so. Against the wishes of her husband, she insisted that her daughter bring the baby home. She then became busily engaged in helping to care for this child exclusively. She thus appeared to satisfy her need through her daughter. some
1.
Philp,
A. F.
Family Failure. London,
1963.
The families investigated had an impoverished background and poor personality nourishment, and consequently many difficulties to face. They could easily find the operation to be a convenient and welcome peg upon which to hang all the blame for their problems. These considerations indicate the need for very guarded action as far as sterilisation is concerned. With such a small number of cases it is not possible to reach any conclusion, though my colleagues and I should have liked to follow up the possibility of some connection between sterilisation and incest. We felt that sterilisation in these cases seemed to put further strain on the unity of families which social workers were striving to maintain. Possibly better and more efficient counselling on the use of contraceptives would be the best approach with this type of family, since this would not lead to the loss of the ability to conceive. Parkstone, Poole, Dorset. JAMES R. LAUGHARNE. A SELF-ADJUSTING CHIN-SUPPORT
SIR,-Respiratory obstruction in non-intubated ansesthetised unconscious patients can usually be prevented by using an oropharyngeal airway and holding the mandible upwards and forwards. A satisfactory support for the chin which leaves the hands free has been devised with a simple quoit. This is a ring of ’Sorbo ’ sponge rubber, 17 cm. in diameter, used for playing quoits or deck-tennis. The patient, asleep and with slack neck muscles, is positioned with the head slightly rotated. The quoit is then compressed so that it slips in between the mandible and clavicle. Adjusting itself to the length of the neck the ring adopts an oval shape and its natural resilience thrusts the chin upwards (see figure). The position of the or
Sorbo
quoit
in
position
as a
chin-support.
the clavicle may be varied according to the shape and dimensions of the neck. In some individuals it sits snugly between the root of the neck and the clavicle. In others it rests on the junction of the middle and outer third of the bone above the deltopectoral triangle. A thin layer of clothing or a theatre-gown gives the quoit a better grip in the latter position. Respiration must be observed as always. This device has been used for patients from the age of 7 years upwards, having neck circumferences ranging from 23 to 44 cm. (9-171/2 in.), with related variations in length. In all cases a completely satisfactory airway has been maintained without any further attention.
quoit on
The sorbo quoit 3s. 9d.
can
be obtained from sports
Department of Anæsthetics, General Hospital, Newcastle upon Tyne NE4 6BE.
outfitters, and
co;ts
L. J. DUNKIN.