- Email: [email protected]
INTRATHECAL METHOTREXATE
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.
381 12 mg. per sq.m. given prophylactically every 90 days and therapeutically weekly is well tolerated and not associated with serious neurological complications. We do not agree that a smaller and much more frequent dose schedule should replace the more widely used schemes. Department of Oncology, Children’s Hospital, Denver, Colorado, U.S.A.
EDWARD S. BAUM CHARLENE P. HOLTON.
CARCINOMA OF THE ŒSOPHAGUS AFTER GASTRIC SURGERY
SIR,-We reported1 that, in
our
necropsy material from
Ulleval Hospital, previous gastric operations for benign conditions were two to three times more common among patients with gastric cancer than among controls matched for age, sex, and year of necropsy. In an earlier report, Shearman et awl. indicated that a similar association may exist between carcinoma of the oesophagus and previous
gastric
surgery.
CARCINOMA OF THE (ESOPHAGUS AFTER GASTRIC SURGERY
MORBIDITY AND MORTALITY IN RELATION TO SOCIAL CLASS
Sm,—Your readers may like to know that the suggestion of Dr. Wald (Jan. 29, p. 259) has already been implemented in the Commentary (vol. III, 1965) of the Hospital InPatient Enquiry, 1960-61. Hospital admissions analysed by occupation and social class have enabled the potentiality of this method to be assessed. Information from hospital patients is, as your correspondent stresses, less precise than that obtained at Census time; in addition, the concept of social class as reflected in official statistics needs handling with care. For example, the proportion recorded in social class v in 1951 was 12-7%, but only 8-0% in the 1961 census-a smaller proportion and presumably further removed from the overall average. There are suggestions that the characteristics which lead families into social-class-v status also cause them to be insouciant of the best action to prevent or deal with disease and injuries-cigarette-smoking can be quoted as one example. Finally, the data displayed is of relative deterioration, whereas the absolute mortality-rates have improved in all classes. Office of Population Censuses and Surveys, Somerset House,
Strand, London WC2R
1LR.
WILLIAM A. WILSON.
VEGETARIANISM AND DRUG USERS
We have reviewed all necropsy reports on patients dying from or with cancer of the oesophagus in Ulleval Hospital in 1960-70. Wherever the reports gave any indication that the patient might have been subjected to gastric surgery for a benign condition, further information was sought from clinical records. The control group from our study on gastric cancerwas used for comparison. These controls were drawn from the necropsy material of the same laboratory from the same years except 1970, and the mean age of the controls was close to that of the patients with cancer of the oesophagus. As shown in the accompanying table, previous gastric surgery was even less common among patients with cancer of the oesophagus than among the controls, although this difference is not a significant one. As in the gastric-cancer study, only operations performed five years or more before death were listed in the table. The two patients with oesophageal cancer had been operated on six and twenty-one years before death. A third male patient with cancer of the oesophagus had been operated on for gastric haemorrhage four years before death, and a fourth, also a male, had undergone partial gastrectomy for a cancerous gastric ulcer eleven years before he died from cancer of the oesophagus. In all four patients the centre of the tumour was in the middle third of the oesophagus and histological examination showed squamous-cell carcinoma. Thus, there is nothing in our data to indicate that cancer of the oesophagus has any peculiar features in patients who have undergone gastric surgery, either in appearance or in frequency. Our observations agree with those of MacDonald et al.,3 who studied patients treated for rectal cancer as controls. Cancer Registry of Norway and Department of Pathology, Ullevål Hospital, HELGE STALSBERG. Oslo 1, Norway. 1. 2.
Stalsberg, H., Taksdal, S. Lancet, 1971, ii, 1175. Shearman, D. J. C., Finlayson, N. D. C., Amott, S. J., Pearson, J. G. ibid. 1970, i, 581. 3. MacDonald, J. B., Waissbluth, J. G., Langman, M. J. S. ibid. 1971, i, 19.
SiR,—The density of errors is high in the letter by Dr. Dwyer and Professor Mayer (Dec. 25, p. 1429). A vegan is one who takes no animal substance as food. Those who take only milk and eggs are called lacto-ovo vegetarians. Both types are found among the Seventh Day Adventists. Hindus are expected to be vegans. The acknowledged authority on vegetarianism is Prof. Mervyn Hardinge, now dean of the School of Public Health, Loma Linda University, Loma Linda, California. Dr. Hardinge wrote his PH.D. dissertation on the health status of vegetarians. He found true vegans rare, even among Seventh Day Adventists, and to have significantly more ill health, especially anaernÏa.2 Thus, vegans do not have superior health. This work was actually done in the department of nutrition at Harvard. Dr. Mayer reminds me of the old Creole saying, " the last thing a fish would discover is water ! ". The pejorative term " hard-core ", used repeatedly by Dr. Dwyer and Professor Mayer to describe vegetarians, is inappropriate. Would the authors refer to a hard-core Catholic or a hard-core Frenchman ? This term, by usage, is reserved for criminality, and vegetarianism is not that. To contend, without data, that vegetarianism is a crutch for drug usage, is also unfair. Our experience indicates that the recourse of American youth to vegetarianism is based on two rationalisations. Those who emphasise a doctrine of love do not wish to see animals victimised for food usage. The mistrust of the rambunctious food technologists who add chemicals with little attention to human safety leads many health-conscious people to seek unprocessed, natural foods for their health protection. Thus, many feel a vegetarian diet is the best recourse in an era of promiscuous manipulation of the food-supply. Dr. Dwyer and Professor Mayer, finally, solicited only confirmation of their views. I suppose they intended to encourage all the facts and opinions. Department of Biochemistry, Division of Nutrition, School of Medicine, Vanderbilt University, Nashville, Tennessee 37232, U.S.A. 1. 2.
GEORGE V. MANN.
Hardinge, M. G. The Health Status of Vegetarians. Dissertation, Harvard University School of Public Health. Boston, 1954. Hardinge, M. G., Stare., F. J. J. clin. Nutr. 1954, 2, 73.
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.
381 12 mg. per sq.m. given prophylactically every 90 days and therapeutically weekly is well tolerated and not associated with serious neurological complications. We do not agree that a smaller and much more frequent dose schedule should replace the more widely used schemes. Department of Oncology, Children’s Hospital, Denver, Colorado, U.S.A.
EDWARD S. BAUM CHARLENE P. HOLTON.
CARCINOMA OF THE ŒSOPHAGUS AFTER GASTRIC SURGERY
SIR,-We reported1 that, in
our
necropsy material from
Ulleval Hospital, previous gastric operations for benign conditions were two to three times more common among patients with gastric cancer than among controls matched for age, sex, and year of necropsy. In an earlier report, Shearman et awl. indicated that a similar association may exist between carcinoma of the oesophagus and previous
gastric
surgery.
CARCINOMA OF THE (ESOPHAGUS AFTER GASTRIC SURGERY
MORBIDITY AND MORTALITY IN RELATION TO SOCIAL CLASS
Sm,—Your readers may like to know that the suggestion of Dr. Wald (Jan. 29, p. 259) has already been implemented in the Commentary (vol. III, 1965) of the Hospital InPatient Enquiry, 1960-61. Hospital admissions analysed by occupation and social class have enabled the potentiality of this method to be assessed. Information from hospital patients is, as your correspondent stresses, less precise than that obtained at Census time; in addition, the concept of social class as reflected in official statistics needs handling with care. For example, the proportion recorded in social class v in 1951 was 12-7%, but only 8-0% in the 1961 census-a smaller proportion and presumably further removed from the overall average. There are suggestions that the characteristics which lead families into social-class-v status also cause them to be insouciant of the best action to prevent or deal with disease and injuries-cigarette-smoking can be quoted as one example. Finally, the data displayed is of relative deterioration, whereas the absolute mortality-rates have improved in all classes. Office of Population Censuses and Surveys, Somerset House,
Strand, London WC2R
1LR.
WILLIAM A. WILSON.
VEGETARIANISM AND DRUG USERS
We have reviewed all necropsy reports on patients dying from or with cancer of the oesophagus in Ulleval Hospital in 1960-70. Wherever the reports gave any indication that the patient might have been subjected to gastric surgery for a benign condition, further information was sought from clinical records. The control group from our study on gastric cancerwas used for comparison. These controls were drawn from the necropsy material of the same laboratory from the same years except 1970, and the mean age of the controls was close to that of the patients with cancer of the oesophagus. As shown in the accompanying table, previous gastric surgery was even less common among patients with cancer of the oesophagus than among the controls, although this difference is not a significant one. As in the gastric-cancer study, only operations performed five years or more before death were listed in the table. The two patients with oesophageal cancer had been operated on six and twenty-one years before death. A third male patient with cancer of the oesophagus had been operated on for gastric haemorrhage four years before death, and a fourth, also a male, had undergone partial gastrectomy for a cancerous gastric ulcer eleven years before he died from cancer of the oesophagus. In all four patients the centre of the tumour was in the middle third of the oesophagus and histological examination showed squamous-cell carcinoma. Thus, there is nothing in our data to indicate that cancer of the oesophagus has any peculiar features in patients who have undergone gastric surgery, either in appearance or in frequency. Our observations agree with those of MacDonald et al.,3 who studied patients treated for rectal cancer as controls. Cancer Registry of Norway and Department of Pathology, Ullevål Hospital, HELGE STALSBERG. Oslo 1, Norway. 1. 2.
Stalsberg, H., Taksdal, S. Lancet, 1971, ii, 1175. Shearman, D. J. C., Finlayson, N. D. C., Amott, S. J., Pearson, J. G. ibid. 1970, i, 581. 3. MacDonald, J. B., Waissbluth, J. G., Langman, M. J. S. ibid. 1971, i, 19.
SiR,—The density of errors is high in the letter by Dr. Dwyer and Professor Mayer (Dec. 25, p. 1429). A vegan is one who takes no animal substance as food. Those who take only milk and eggs are called lacto-ovo vegetarians. Both types are found among the Seventh Day Adventists. Hindus are expected to be vegans. The acknowledged authority on vegetarianism is Prof. Mervyn Hardinge, now dean of the School of Public Health, Loma Linda University, Loma Linda, California. Dr. Hardinge wrote his PH.D. dissertation on the health status of vegetarians. He found true vegans rare, even among Seventh Day Adventists, and to have significantly more ill health, especially anaernÏa.2 Thus, vegans do not have superior health. This work was actually done in the department of nutrition at Harvard. Dr. Mayer reminds me of the old Creole saying, " the last thing a fish would discover is water ! ". The pejorative term " hard-core ", used repeatedly by Dr. Dwyer and Professor Mayer to describe vegetarians, is inappropriate. Would the authors refer to a hard-core Catholic or a hard-core Frenchman ? This term, by usage, is reserved for criminality, and vegetarianism is not that. To contend, without data, that vegetarianism is a crutch for drug usage, is also unfair. Our experience indicates that the recourse of American youth to vegetarianism is based on two rationalisations. Those who emphasise a doctrine of love do not wish to see animals victimised for food usage. The mistrust of the rambunctious food technologists who add chemicals with little attention to human safety leads many health-conscious people to seek unprocessed, natural foods for their health protection. Thus, many feel a vegetarian diet is the best recourse in an era of promiscuous manipulation of the food-supply. Dr. Dwyer and Professor Mayer, finally, solicited only confirmation of their views. I suppose they intended to encourage all the facts and opinions. Department of Biochemistry, Division of Nutrition, School of Medicine, Vanderbilt University, Nashville, Tennessee 37232, U.S.A. 1. 2.
GEORGE V. MANN.
Hardinge, M. G. The Health Status of Vegetarians. Dissertation, Harvard University School of Public Health. Boston, 1954. Hardinge, M. G., Stare., F. J. J. clin. Nutr. 1954, 2, 73.