1285
legalised it. Nevertheless abortion is destruction of human life. Killing has to be either right or wrong and our society needs a courageous voice to declare good as good and evil as evil, lest our growing children be unable to distinguish them. Embryo research is "acceptable" because we arbitrarily decide that embryos under 14 days old are not persons and thus not subject to the protection given to other research subjects. Your editorial argues for a society built on individual conscience but with no clear idea of right and wrong. has
Department of Medicine, Queen Elizabeth Hospital, Birmingham B15 2TH. UK
C. A. HAFFNER
Advertising for medical
research funds
viewed
Department of Surgery, Bristol Royal Infirmary,
STEWART NICHOLSON
Bristol BS2 8HW, UK
1. Fisher B, Redmond C, Poisson R, et al. Eight year results of a randomized clinical trial comparing total mastectomy and lumpectomy with or without radiation in the treatment of breast cancer. N Engl J Med 1989; 320: 822-28. 2. Wilson RG, Hart A, Dawes PJDK. Mastectomy or conservation: the patient’s choice. Br Med J 1988; 297: 1167-69. 3 Barr LC, Brunt AM, Goodman AG, et al. Uncontrolled local recurrence after treatment of breast cancer with breast conservation. Cancer 1989; 64: 1203-07.
Does hip dislocation matter in cerebral
palsy? SiR,—The final paragraph of your April 7 editorial may have left an unwarranted impression on many of your readers who see but a few children with cerebral palsy. You say "Results of prophylactic surgery are poor in severely involved quadriplegic children, especially if subluxation or dislocation occur early in life". You cite Kalen and Bleck,l Sharrard et a1,2 and Banks and Greento support
this view. Kalen and Bleck investigated the efficacy of soft-tissue-only
surgery and they concluded "Unfortunately, successful results
be expected in only about sixty percent of non-ambulators
flexion and adduction even when all overactive adductor and flexor forces have been eliminated or balanced. Even this is a considerable improvement on the dislocated, painful hip in a grossly deformed child that is the almost invariable result of purely conservative
management".
with dismay the latest money-raising advertisements by the Imperial Cancer Research Fund (ICRF). A two-page colour advertisement, for example, in the May 5-11 issue of the Radio Times depicts in an emotive and grossly misleading fashion the difference between total mastectomy and "conservation" surgery. The advertisement shows the breast of a young woman, probably in her early 20s. In 1984, according to Cancer Research Campaign statistics, there were only 27 cases of breast cancer reported in England and Wales in women under the age of 25. The text implies, incorrectly, that good "conservation" surgery is minimal. Conservation surgery requires a wide removal of tumour-bearing tissue and axillary nodes should be sampled,l a point not made in the advertisement. Surgery is only a part of conservation therapy. These women will have to have postoperative radiotherapy which may mean five or six weeks of intensive outpatient treatment at a specialised unit which may be a long way from their homes and, indeed, from the unit where the surgery was done. This is one reason why many women prefer mastectomy.2 The criteria for selecting which of the currently available treatments is most suited to a woman with breast cancer have been clearly documented and many women have disease which would be inappropriately treated by conservation. The ICRF played only a part in this original research and it did not pioneer conservation therapy, as the advertisement implies. The consequences of the wrong therapeutic choice in terms of unacceptable rates of local recurrence (which then often requires mastectomy) or of uncontrolled local recurrence (which is virtually untreatable) make it the responsibility of surgeons involved in the care of these women to recommend treatment carefully on an individual basis.3 It is wholly inaccurate to depict mastectomy as outdated or old-fashioned. Even with careful selection conservation therapy gives results in terms of disease control and long-term survival no different from mastectomy. ICRF should not be using advertising tactics of this sort.
SiR,—I
patients with scoliosis or pelvic obliquity and frequently additional bony surgery (.......) will be necessary to prevent dislocation of the hip Sharrard and colleagues’ fourth conclusion was "The need for operation is independent of age, severity of involvement or neurological maturity of the child". And earlier they had written "The most difficult were the severely affected, neurologically immature tetraplegic children, in whom the most that can be expected is a dysplastic or mildly subluxated hip that still falls into
can or
Banks and Green’s results are not easy to analyse since the scoring not entirely clear (the preoperative hip state is not taken into account). But their work in no way supports your statement with respect to the prevention of dislocation. Surgery around the hip in cerebral palsy is not solely for functional gain but frequently for an improvement in the patient’s lifestyle, prevention of secondary deformity, and to ease the burden of care. You state,"Since the unstable hip does not necessarily cause functional complications to many such patients", but Cooperman et al4 estimate that half the dislocated hips will give rise to pain. To withhold early prophylactic surgery on current evidence is not a decision I would care to make on someone else’s behalf. is
Newcomen Centre,
Guy’s Hospital,
DAVID SCRUTTON
London SE1 9RT, UK
1. Kalen
V, Bleck EE. Prevention of spastic paralytic dislocation of the hip. Dev Med Child Neurol 1985; 27: 17-24. 2. Sharrard WJW, Allen JMH, Heaney SH. Surgical prophylaxis of subluxation and dislocation of the hip in cerebral palsy. J Bone Joint Surg 1975; 57B: 160-66. 3. Banks HH, Green WT. Adductor myotomy and obturator neurectomy for the correction of adduction contracture of the hip m cerebral palsy.J Bone Joint Surg 1960; 42A: 111-26. 4. Cooperman DR, Bartucci E, Dietrick E, Millar EA. Hip dislocation in spastic cerebral palsy: long-term consequences. J Ped Orthop 1987; 7: 268-76.
Vitamin
B12 deficiency and multiple sclerosis
S1R,- Vitamin B12 deficiency associated with pernicious anaemia in the differential diagnosis of neurological syndromes is regarded as compatible with multiple sclerosis (MS). Such consideration is especially salient when the neurological syndrome is characteristic of vitamin B12 deficiency. We report a patient who presented with asymmetrical neurological symptoms which reproducibly remitted in response to corticotropin (ACTH) and corticosteroids. A 46-year-old woman had painful paraesthesias associated with progressive right leg weakness. Myelography was normal. MS was diagnosed. During the following 15 years she was admitted about every 18 months for exacerbation of symptoms, and each time was treated with ACTH infusions which resulted in improvement. In June, 1987, magnetic resonance imaging of the brain showed bilateral high-signal-intensity abnormalities in the white matter. About 2 months later, a mean cell volume (MCV) of 100 fl was recorded. In 1988, at age 61 she was first seen by us, 5 months after exacerbation. At that time she denied cranial nerve, cerebellar, visual, or cognitive symptoms and noted that she was regarded as a "shark" at the poker table. She did not drink alcohol. She reported ocular myasthenia gravis in a brother and systemic lupus erythematosus in a sister. She had severe spastic monoparesis of the right leg associated with distal wasting. Vibration appreciation was bilaterally absent in the feet, with decreased pinprick appreciation to the mid-thigh on the right. Reflexes were symmetrically depressed with bilateral plantar extensor responses. The leucocyte count was 63 x 10/jil, haemoglobin 14 4 g/dl, mean corpuscular volume (MCV) 98-3 fl, and platelet count 163 000/1. The blood smear contained rare hypersegmented polymorphonuclear leucocytes. Serum vitamin B12 was less than 100 pg/ml and folic acid 8-2 ng/ml. Rheumatoid factor was raised (67 lU/ml) with an antinuclear factor
legalised it. Nevertheless abortion is destruction of human life. Killing has to be either right or wrong and our society needs a courageous voice to declare good as good and evil as evil, lest our growing children be unable to distinguish them. Embryo research is "acceptable" because we arbitrarily decide that embryos under 14 days old are not persons and thus not subject to the protection given to other research subjects. Your editorial argues for a society built on individual conscience but with no clear idea of right and wrong. has
Department of Medicine, Queen Elizabeth Hospital, Birmingham B15 2TH. UK
C. A. HAFFNER
Advertising for medical
research funds
viewed
Department of Surgery, Bristol Royal Infirmary,
STEWART NICHOLSON
Bristol BS2 8HW, UK
1. Fisher B, Redmond C, Poisson R, et al. Eight year results of a randomized clinical trial comparing total mastectomy and lumpectomy with or without radiation in the treatment of breast cancer. N Engl J Med 1989; 320: 822-28. 2. Wilson RG, Hart A, Dawes PJDK. Mastectomy or conservation: the patient’s choice. Br Med J 1988; 297: 1167-69. 3 Barr LC, Brunt AM, Goodman AG, et al. Uncontrolled local recurrence after treatment of breast cancer with breast conservation. Cancer 1989; 64: 1203-07.
Does hip dislocation matter in cerebral
palsy? SiR,—The final paragraph of your April 7 editorial may have left an unwarranted impression on many of your readers who see but a few children with cerebral palsy. You say "Results of prophylactic surgery are poor in severely involved quadriplegic children, especially if subluxation or dislocation occur early in life". You cite Kalen and Bleck,l Sharrard et a1,2 and Banks and Greento support
this view. Kalen and Bleck investigated the efficacy of soft-tissue-only
surgery and they concluded "Unfortunately, successful results
be expected in only about sixty percent of non-ambulators
flexion and adduction even when all overactive adductor and flexor forces have been eliminated or balanced. Even this is a considerable improvement on the dislocated, painful hip in a grossly deformed child that is the almost invariable result of purely conservative
management".
with dismay the latest money-raising advertisements by the Imperial Cancer Research Fund (ICRF). A two-page colour advertisement, for example, in the May 5-11 issue of the Radio Times depicts in an emotive and grossly misleading fashion the difference between total mastectomy and "conservation" surgery. The advertisement shows the breast of a young woman, probably in her early 20s. In 1984, according to Cancer Research Campaign statistics, there were only 27 cases of breast cancer reported in England and Wales in women under the age of 25. The text implies, incorrectly, that good "conservation" surgery is minimal. Conservation surgery requires a wide removal of tumour-bearing tissue and axillary nodes should be sampled,l a point not made in the advertisement. Surgery is only a part of conservation therapy. These women will have to have postoperative radiotherapy which may mean five or six weeks of intensive outpatient treatment at a specialised unit which may be a long way from their homes and, indeed, from the unit where the surgery was done. This is one reason why many women prefer mastectomy.2 The criteria for selecting which of the currently available treatments is most suited to a woman with breast cancer have been clearly documented and many women have disease which would be inappropriately treated by conservation. The ICRF played only a part in this original research and it did not pioneer conservation therapy, as the advertisement implies. The consequences of the wrong therapeutic choice in terms of unacceptable rates of local recurrence (which then often requires mastectomy) or of uncontrolled local recurrence (which is virtually untreatable) make it the responsibility of surgeons involved in the care of these women to recommend treatment carefully on an individual basis.3 It is wholly inaccurate to depict mastectomy as outdated or old-fashioned. Even with careful selection conservation therapy gives results in terms of disease control and long-term survival no different from mastectomy. ICRF should not be using advertising tactics of this sort.
SiR,—I
patients with scoliosis or pelvic obliquity and frequently additional bony surgery (.......) will be necessary to prevent dislocation of the hip Sharrard and colleagues’ fourth conclusion was "The need for operation is independent of age, severity of involvement or neurological maturity of the child". And earlier they had written "The most difficult were the severely affected, neurologically immature tetraplegic children, in whom the most that can be expected is a dysplastic or mildly subluxated hip that still falls into
can or
Banks and Green’s results are not easy to analyse since the scoring not entirely clear (the preoperative hip state is not taken into account). But their work in no way supports your statement with respect to the prevention of dislocation. Surgery around the hip in cerebral palsy is not solely for functional gain but frequently for an improvement in the patient’s lifestyle, prevention of secondary deformity, and to ease the burden of care. You state,"Since the unstable hip does not necessarily cause functional complications to many such patients", but Cooperman et al4 estimate that half the dislocated hips will give rise to pain. To withhold early prophylactic surgery on current evidence is not a decision I would care to make on someone else’s behalf. is
Newcomen Centre,
Guy’s Hospital,
DAVID SCRUTTON
London SE1 9RT, UK
1. Kalen
V, Bleck EE. Prevention of spastic paralytic dislocation of the hip. Dev Med Child Neurol 1985; 27: 17-24. 2. Sharrard WJW, Allen JMH, Heaney SH. Surgical prophylaxis of subluxation and dislocation of the hip in cerebral palsy. J Bone Joint Surg 1975; 57B: 160-66. 3. Banks HH, Green WT. Adductor myotomy and obturator neurectomy for the correction of adduction contracture of the hip m cerebral palsy.J Bone Joint Surg 1960; 42A: 111-26. 4. Cooperman DR, Bartucci E, Dietrick E, Millar EA. Hip dislocation in spastic cerebral palsy: long-term consequences. J Ped Orthop 1987; 7: 268-76.
Vitamin
B12 deficiency and multiple sclerosis
S1R,- Vitamin B12 deficiency associated with pernicious anaemia in the differential diagnosis of neurological syndromes is regarded as compatible with multiple sclerosis (MS). Such consideration is especially salient when the neurological syndrome is characteristic of vitamin B12 deficiency. We report a patient who presented with asymmetrical neurological symptoms which reproducibly remitted in response to corticotropin (ACTH) and corticosteroids. A 46-year-old woman had painful paraesthesias associated with progressive right leg weakness. Myelography was normal. MS was diagnosed. During the following 15 years she was admitted about every 18 months for exacerbation of symptoms, and each time was treated with ACTH infusions which resulted in improvement. In June, 1987, magnetic resonance imaging of the brain showed bilateral high-signal-intensity abnormalities in the white matter. About 2 months later, a mean cell volume (MCV) of 100 fl was recorded. In 1988, at age 61 she was first seen by us, 5 months after exacerbation. At that time she denied cranial nerve, cerebellar, visual, or cognitive symptoms and noted that she was regarded as a "shark" at the poker table. She did not drink alcohol. She reported ocular myasthenia gravis in a brother and systemic lupus erythematosus in a sister. She had severe spastic monoparesis of the right leg associated with distal wasting. Vibration appreciation was bilaterally absent in the feet, with decreased pinprick appreciation to the mid-thigh on the right. Reflexes were symmetrically depressed with bilateral plantar extensor responses. The leucocyte count was 63 x 10/jil, haemoglobin 14 4 g/dl, mean corpuscular volume (MCV) 98-3 fl, and platelet count 163 000/1. The blood smear contained rare hypersegmented polymorphonuclear leucocytes. Serum vitamin B12 was less than 100 pg/ml and folic acid 8-2 ng/ml. Rheumatoid factor was raised (67 lU/ml) with an antinuclear factor
