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HOW SAFE IS ABORTION ?
380 assessment is only one of the aims of this science. Of course it needs a clear, defined structure, and I agree that the assessment should be conducted by a " specialist " rather than by the all-comer. I realise that many doctors feel themselves ill-equipped for such a task. Therefore, before dismissing developmental paediatrics as a non-starter perhaps your correspondents should reassess their feelings. If they still fail to find empathy, perhaps they should go deeper into the subject by taking time off to attend one of the excellent courses available. There is at present a continuous trend away from pure pxdiatrics, with its traditional emphasis on diagnosis and treatment of acute medical problems, towards developmental paediatrics. Since this trend is likely to continue, now is the time for all who have the welfare of our children at heart to get to terms with this new science. Park Hospital for Children,
Developmental new
Old Road, Headington, Oxford OX3 7LQ.
MICHAEL A. SALMON.
HOW SAFE IS ABORTION ?
SiR,—The study by Professor Stallworthy and his colleagues at Oxford of the risks of legal abortion (Dec. 4, p. 1245) has underlined our own findings1 of a high rate of complications. Both studies disclosed many major and minor complications, excluding the long-term effects, such as cervical incompetence and sterility. Women requesting termination of pregnancy are treated like any other patient in our gynxcological ward. We try to be sympathetic and understanding, we do not instil guilt into our patients, and naturally we operate to the best of our abilities. Nevertheless, the long list of complications is disquieting. Patients are often admitted to our wards after abortion at clinics in and around London. In some cases the may be seriously ill, but often the complication is minor. In most cases the surgeon who operated is unaware of the complication, and often the patient is just referred to " our casualty department. 16% of flying-squad " cases from this hospital in the last two years were to surrounding private clinics where complications had arisen during operations for termination of pregnancy. As Mr. Moolgaoker suggests (Jan. 29, p. 264), could Dr. Price (Dec. 25, p. 1419) be understating the complication-rate in the private sector ? I look forward to the results of the follow-up which the Pregnancy Advisory Service is now undertaking.
private patient
West Middlesex Hospital, Isleworth, Middlesex.
SATYA V. SOOD.
LEPROSY AND VITILIGO
SIR,—The letter from Dr. Silverton (Jan. 22, p. 200) refers to leprosy as a possible cause of " vitiligo ". While it is true that leprosy is one of the commonest causes of partial loss of pigment in a single circumscribed area of skin or in many ill-defined macules, leprosy lesions almost never completely lose pigment as happens in typical vitiligo. Furthermore, localised leucotrichia is an extremely rare occurrence in leprosy. Another point: enlargement of the ulnar nerve above the humeral epicondyle can scarcely be regarded as a " first sign " of leprosy. Unilateral and localised departures from the normal at this site-in size, consistence, and tenderness-are useful confirmatory signs of the established disease. The misleading term " white leprosy " refers to vitiligo, and not to leprosy. The recent work of Lerner, referred to in your editorial 1. Sood,
S. V. Br. med. J. 1971,
iv,
270.
of Dec. 11 (p. 1298), on a possible neurogenic factor in the production of vitiligo, may have a bearing on the hitherto unexplained partial loss of pigment in leprosy lesions of the skin in which widespread damage to nerve tissue in the dermis is a feature. The Leprosy Study Centre, 57a Wimpole Street, London W.1.
S. G. BROWNE.
REPIGMENTATION OF TRAUMATIC VITILIGO SiR,—This anecdote may be of value to those studying pigmentary skin changes. A very dark-skinned Jamaican sustained a superficial burn on the back of his right wrist. This healed by complete regeneration of the epidermis without scarring, but left After four an area of vitiligo roughly 2 in. in diameter. months, pigment reappeared as a mosaic of tiny brown macules surrounding the hair follicles. These increased in diameter until coalescence occurred after a further six months, the whole area being repigmented but still a shade lighter than the surrounding skin. After a further six months the original skin colour was completely restored and matched the colour of the adjacent unaffected skin. No treatment, other than dry dressing to the original burn, was
given. 8
Nursery Lane,
Leeds LS17 7HN.
NEVIL SILVERTON.
INTRATHECAL METHOTREXATE
SiR,-Serious neurological complications after the administration of intrathecal methotrexate in the treatment or prophylaxis of leukaemic meningitis or treatment of choriocarcinoma have been reported.’-’ Suggested causes of the complications include direct hypersensitivity reactions related to methotrexate,4 to its preservatives, or to benzyl alcohol, which is used as a preservative in some diluents. Use of a diluent not containing a preservative has not prevented the5 commonest neurological reaction-chemical arachnoiditis.5 It has been suggested that doses of 10 .g. per kg. daily, and thereafter every 2-3 days, are not associated with neurological complications and should be used in place of the widely adopted single doses of 150-500 (.Lg. per kg. (4-5-15-0 mg. per sq.m.).8 At the Children’s Hospital Oncology Center, since January, 1969, 161 prophylactic and 121 therapeutic doses of intrathecal methotrexate have been given to 45 patients. Almost all doses were based on a calculation of 12 mg. per sq.m. The prophylactic doses were given every 90 days, and the therapeutic doses were given weekly. A diluent containing no preservatives was used exclusively. No serious neurological complications have been observed. The only neurological reaction has been infrequent arachnoiditis which resolved in all cases. A schedule of spinal taps daily or every 2-3 days has two disadvantages. First, a decrease in the interval between taps is associated with an increase in dry and/or unsuccessful taps; second, more frequent taps add significantly to the emotional trauma experienced by patients, especially children. In our hands, intrathecal methotrexate in a dose of Sullivan, M. P., Windmiller, J. Med. Rec. Ann., Houston, 1966, 59, 92. 2. Back, E. H. Lancet, 1969, ii, 1005. 3. Rosner, F., Lee, S. L., Kagen, M., Morrison, A. N. ibid. 1970, i, 249. 4. Pasquinucci, G., Pardini, R., Fedi, F. ibid. p. 309. 5. Naiman, J. L., Rupprecht, L. M., Tanyeri, G., Philippidis, P. ibid. 1970, i, 571. 6. Baum, E. S., Koch, H. F., Corby, D. G., Plunket, D. C. ibid. 1971, i, 649. 7. Bagshawe, K. D., Magrath, I. T., Golding, P. R. ibid. 1969, ii, 1258. 8. Mollica, F., Schiliro, G., Pavone, L., Collica, F. ibid. 1971, ii, 771. 1.
Developmental new
Old Road, Headington, Oxford OX3 7LQ.
MICHAEL A. SALMON.
HOW SAFE IS ABORTION ?
SiR,—The study by Professor Stallworthy and his colleagues at Oxford of the risks of legal abortion (Dec. 4, p. 1245) has underlined our own findings1 of a high rate of complications. Both studies disclosed many major and minor complications, excluding the long-term effects, such as cervical incompetence and sterility. Women requesting termination of pregnancy are treated like any other patient in our gynxcological ward. We try to be sympathetic and understanding, we do not instil guilt into our patients, and naturally we operate to the best of our abilities. Nevertheless, the long list of complications is disquieting. Patients are often admitted to our wards after abortion at clinics in and around London. In some cases the may be seriously ill, but often the complication is minor. In most cases the surgeon who operated is unaware of the complication, and often the patient is just referred to " our casualty department. 16% of flying-squad " cases from this hospital in the last two years were to surrounding private clinics where complications had arisen during operations for termination of pregnancy. As Mr. Moolgaoker suggests (Jan. 29, p. 264), could Dr. Price (Dec. 25, p. 1419) be understating the complication-rate in the private sector ? I look forward to the results of the follow-up which the Pregnancy Advisory Service is now undertaking.
private patient
West Middlesex Hospital, Isleworth, Middlesex.
SATYA V. SOOD.
LEPROSY AND VITILIGO
SIR,—The letter from Dr. Silverton (Jan. 22, p. 200) refers to leprosy as a possible cause of " vitiligo ". While it is true that leprosy is one of the commonest causes of partial loss of pigment in a single circumscribed area of skin or in many ill-defined macules, leprosy lesions almost never completely lose pigment as happens in typical vitiligo. Furthermore, localised leucotrichia is an extremely rare occurrence in leprosy. Another point: enlargement of the ulnar nerve above the humeral epicondyle can scarcely be regarded as a " first sign " of leprosy. Unilateral and localised departures from the normal at this site-in size, consistence, and tenderness-are useful confirmatory signs of the established disease. The misleading term " white leprosy " refers to vitiligo, and not to leprosy. The recent work of Lerner, referred to in your editorial 1. Sood,
S. V. Br. med. J. 1971,
iv,
270.
of Dec. 11 (p. 1298), on a possible neurogenic factor in the production of vitiligo, may have a bearing on the hitherto unexplained partial loss of pigment in leprosy lesions of the skin in which widespread damage to nerve tissue in the dermis is a feature. The Leprosy Study Centre, 57a Wimpole Street, London W.1.
S. G. BROWNE.
REPIGMENTATION OF TRAUMATIC VITILIGO SiR,—This anecdote may be of value to those studying pigmentary skin changes. A very dark-skinned Jamaican sustained a superficial burn on the back of his right wrist. This healed by complete regeneration of the epidermis without scarring, but left After four an area of vitiligo roughly 2 in. in diameter. months, pigment reappeared as a mosaic of tiny brown macules surrounding the hair follicles. These increased in diameter until coalescence occurred after a further six months, the whole area being repigmented but still a shade lighter than the surrounding skin. After a further six months the original skin colour was completely restored and matched the colour of the adjacent unaffected skin. No treatment, other than dry dressing to the original burn, was
given. 8
Nursery Lane,
Leeds LS17 7HN.
NEVIL SILVERTON.
INTRATHECAL METHOTREXATE
SiR,-Serious neurological complications after the administration of intrathecal methotrexate in the treatment or prophylaxis of leukaemic meningitis or treatment of choriocarcinoma have been reported.’-’ Suggested causes of the complications include direct hypersensitivity reactions related to methotrexate,4 to its preservatives, or to benzyl alcohol, which is used as a preservative in some diluents. Use of a diluent not containing a preservative has not prevented the5 commonest neurological reaction-chemical arachnoiditis.5 It has been suggested that doses of 10 .g. per kg. daily, and thereafter every 2-3 days, are not associated with neurological complications and should be used in place of the widely adopted single doses of 150-500 (.Lg. per kg. (4-5-15-0 mg. per sq.m.).8 At the Children’s Hospital Oncology Center, since January, 1969, 161 prophylactic and 121 therapeutic doses of intrathecal methotrexate have been given to 45 patients. Almost all doses were based on a calculation of 12 mg. per sq.m. The prophylactic doses were given every 90 days, and the therapeutic doses were given weekly. A diluent containing no preservatives was used exclusively. No serious neurological complications have been observed. The only neurological reaction has been infrequent arachnoiditis which resolved in all cases. A schedule of spinal taps daily or every 2-3 days has two disadvantages. First, a decrease in the interval between taps is associated with an increase in dry and/or unsuccessful taps; second, more frequent taps add significantly to the emotional trauma experienced by patients, especially children. In our hands, intrathecal methotrexate in a dose of Sullivan, M. P., Windmiller, J. Med. Rec. Ann., Houston, 1966, 59, 92. 2. Back, E. H. Lancet, 1969, ii, 1005. 3. Rosner, F., Lee, S. L., Kagen, M., Morrison, A. N. ibid. 1970, i, 249. 4. Pasquinucci, G., Pardini, R., Fedi, F. ibid. p. 309. 5. Naiman, J. L., Rupprecht, L. M., Tanyeri, G., Philippidis, P. ibid. 1970, i, 571. 6. Baum, E. S., Koch, H. F., Corby, D. G., Plunket, D. C. ibid. 1971, i, 649. 7. Bagshawe, K. D., Magrath, I. T., Golding, P. R. ibid. 1969, ii, 1258. 8. Mollica, F., Schiliro, G., Pavone, L., Collica, F. ibid. 1971, ii, 771. 1.