of this nature. The whole article is inclined towards conservative treatment, but there is no conservative treatment for a paraoesophageal hernia, which can present with acute symptoms of gastric obstruction. No mention is made of anaemia, which may be a serious complication of both varieties of hiatus hernia, and while it is possible to treat this condition with continuous iron therapy, this is no guarantee against a major haematemesis-and how much better to cure the anaemia and the hernia at the same time by surgery. Why should a patient have to suffer the inconvenience of being propped up in bed at night, not being allowed to eat what he would like to eat, and being unable to bend or stoop, and be offered surgery only when he is complaining of dysphagia due to the development of a stricture? Although it is small, there is an incidence of malignant change in hiatus hernia, another good reason for not persevering with conservative treatment. The operation of abdominal fundoplication is simple and gives good results in the short term, but it has given many thoracic surgeons extremely difficult transthoracic operations when the symptoms recur. Many abdominal surgeons now appreciate that the transthoracic approach gives the best operative field for lesions of the oesophagus and gastrooesophageal junction as, after all, nine-tenths of the oesophagus is a thoracic organ. Perhaps the most surprising omission from your article is that no mention is made of an operation which is being performed in nearly all the thoracic surgical units in Britain, an operation which has been devised on a sound physiological and anatomical basis and gives excellent long-term results-the Belsey mark IV repair. MICHAEL BATES North Middlesex Hospital,

London N18

' Baue, A E, and Belsey, R H R, Surgery, 1967, 62, 396.

SIR,-In your leading article (3 December, p 1436) you advocate surgery only when conservative measures fail to control symptoms of reflux oesophagitis associated with sliding hiatus hernia and in cases with fibrous stricture. In about 10%/ of cases, however, a hiatus hernia cannot be demonstrated radiologically and these patients should not be denied surgery if their symptoms warrant it. Operation is also indicated in severe anaemia due to bleeding from oesophageal ulceration. In my series of 198 patients with sliding hiatus hernia severe anaemia was present in 16 (8 %).1 These patients are often treated for anaemia for years before the underlying pathology is discovered. You discuss the currently popular Nissen's fundoplication. The author himself, however, reported2 that 100/o of his patients had postoperative difficulty in belching and suffered from gastric distension, and four died of

peritonitis. A review of hiatus hernia is incomplete without reference to Philip Allison, who was the first to describe3 an operative method based on restoring the normal anatomical and physiological conditions, which include the subdiaphragmatic fixation of the lower oesophageal segment. This procedure does not produce additional symptoms, but its popularity has declined because of reported high recurrence rates. I have been using a modification of Allison's technique for the past 25 years. At thoracotomy the lower oesophagus is mobilised


and a purse-string inserted around the sac is reduced through a small diaphragmatic incision and stitched to the undersurface of the diaphragm. A few stitches are usually added to fix the sac below the diaphragm and the limbs of the right crus are approximated behind the oesophagus. Sumner' reviewed the clinical findings of 204 of my operations for hiatal hernia, 198 of which were of the sliding variety; 25 of the patients had a tight fibrous stricture preoperatively and thus presented a difficult problem. The assessment 1-10 years following surgery showed that 75 9 % of patients were completely satisfied, 181 0% improved, and 5 9 % dissatisfied. During this follow-up period only two of my patients required surgery for recurrent hernia. Regardless of the method used, surgery should be undertaken only if symptoms are intractable and the patient insists on operation. EUGENE HOFFMAN Poole Hospital, Middlesbrough, Cleveland Hoffman, E, and Sumner, M C, Thorax, 1973, 28, 379. 'Nissen, R, and Rossetti, M J, journal of the International College of Surgeons, 1965, 46, 663. 3 Allison, P R, Surgery, Gynecology and Obstetrics, 1951, 92, 419.

The cancer patient: communication and morale SIR,-"I couldn't think what had happened to my marriage . . .". Dr T B Brewin's excellent article (24-31 December, p 1623) most sensitively setting out guidelines for maintaining communication with patients who "happen to have cancer" appears to us to call for a

21 JANUARY 1978

anxious to give. After many years in general practice I have found that the clergy are always grateful to be told when their parishioners are in hospital. They can then communicate with the patient and the family before meeting them later at the crematorium or graveside. SYLVIA C ELLISON London W10

A problem with ear piercing

SIR,-With regard to the short report by Mr J Cockin and his colleagues (24-31 December, p 1631) my own experience in this field sheds further light on the matter. In response to requests from friends and nursing staff I have been using a Caflon gun, studs, and clasps for about two years. I have had no complications and the series includes two people who had had to remove their previous studs because of inflammation after insertion by a jeweller. The subjects were all people I know, so it is unlikely that complications would not have been reported. Piercing was done with proper asepsis and the studs were adjusted at the end of the procedure to ensure they were not tight and would move freely to and fro in the lobe. Success in the two repeat cases suggests that error by the operator was a more likely cause of the trouble than allergy to the 24-carat gold plating on the studs. The manufacturers give instructions on cleaning the ear lobes and on "no-touch technique" for loading the gun, but no advice on adjusting the stud after insertion. A few problems are probably due to infection from inadequate skin cleaning or touching the stud, but most seem to be due to pressure. My gun inserts studs leaving the head proud and the clasp tightly pressed against the lobe, so that without adjustment pressure damage, swelling, and embedding would probably occur. Spontaneous rectification does not take place, because notches near the tip of the stud, for altering the position of the clasp to allow for different thicknesses of ear lobe, catch in the skin surface. It may be that other guns drive the stud too far through the lobe, leaving it too tight. One would like to know if the patients with embedded studs were initially able to move them to and fro for daily cleaning in accordance with their instruction sheet. I do not think ear piercing with this gun needs to be discouraged, but the manufacturers should supply more precise instructions on its use to prevent complications.

sequel. The patient quoted above had spent two years wondering what was the barrier that had separated him from his wife. She knew the "full facts"; he believed his operation had been a complete success. We met him after he had finally been told of his recurrent disease by his surgeon. When asked, "Back at the beginning, would you rather your wife had been told less or that you had been told more ?" he replied, "The first-but we should have been together." We commonly meet our patients and their families at the later stages of disease. We agree with Hinton that the successful open sharing of stress can bring a special quality to marital (and other) relationships.' Can Dr Brewin and others give us guidance about fostering communication within the family throughout the course of this disease ? Perhaps the tradition of 0 B GIBSON telling the family the full facts needs to be looked at in the same sensitive way that he has Houghton-le-Spring, Tyne and Wear described in relation to patients. Surely what so often occurs tends to separate families rather than to unite them. The Progestasert and ectopic pregnancy CICELY SAUNDERS T S WEST SIR,-Dr R Snowden's observations (17 St Christopher's Hospice, December, p 1600) are of importance to those London SE26 concerned with matters of family planning. The distributors have surely acted correctly Hinton, J M, personal communication, 1971. in ceasing to recommend this device until it can be accurately estimated what is the SIR,-I have read with much interest the ectopic pregnancy rate for an average UK article by Dr Thurstan B Brewin (24-31 populace. Meanwhile we suffer loss. The Progestasert December, p 1623), but I am surprised and distressed that at no point in his communica- did offer satisfactory contraception for a group tion with the patient or relatives does he of older women who had heavy and painful mention the spiritual help that the patient is so menses. If such a useful contraceptive is to be often hungering for and which his parish withdrawn because the ectopic pregnancy rate priest or the hospital chaplain is only too is 20 % of pregnancies occurring, why do some


21 JANUARY 1978


companies market oral contraceptive drugs possibly of interest from a scientific standwith an ectopic rate even higher than 20 % ?I point, must be utterly unjustifiable. The amount of disease which will be produced by ANTHONY D NOBLE cycling in the near future rests with the large body of family physicians in this country, Royal Hampshire County Hospital, whom I am addressing in this essay." Winchester He is mostly concerned with the possibility Liukko, P, and Erkkola, R, British Medical _Journal, of "enlargement of the heart" and with 1976, 2, 1257. valvular disease developing in cyclists. He makes no mention of coronary heart disease. SIR,-In company with many of my colRODERICK HOWELL leagues, I have not used the Progestasert device because of its high cost and short life Swansea, W Glamorgan span. Furthermore, aware of the association of Herschell, G, Cycling as a Cause of Heart Disease. London, Bailliere, Tindall, and Cox, 1896. ectopic pregnancy with IUDs (of 71 ectopic pregnancies treated at Hackney Hospital between January 1973 and February 1977, 10 patients had an IUD in the uterus when the Registration of overseas doctors ectopic pregnancy occurred and a further three had previously used this method of contracep- SIR,-Dr J P N Hicks (24-31 December, tion'), there seemed to be good theoretical p 1674) questions the procedures by which grounds on which to expect an even higher are exempted from the TRAB tests incidence with the Progestasert device. In view persons and infers that if those exempted had been of the statement (17 December, p 1612) that tested a failure rate equivalent to that in the May and Baker are not aware of case reports tests would be likely. from this country, the following report may The evidence available to the General be of interest. does not support this. The Medical A 30-year-old Caucasian patient, mother of exemptionCouncil categories have been most carefully two children aged 3 and 1 year, had a Pro- devised and take account both of the profesgestasert device inserted by her general attainments of the candidates exempted practitioner in April 1977, eight months after sional and, where this seems desirable, the nature of her last delivery. She experienced sudden the employment for which temporary registrasevere lower abdominal pain on 28 July 1977, is to be sought. Since the inception of the nine days after a normal period. She was tion tests the performance of doctors granted admitted to another hospital on 29 July and temporary registration for the first time has treated with antibiotics. She had further been monitored by the council. Adverse severe pain on 7 August and also complained reports have been received on less than 1 % of pain on defaecation. When first seen by of the doctors granted temporary registration me on 16 August she had signs of a pelvic first time. This figure includes not for haematocoele and at operation the next day a onlythe who have passed the test but also large pelvic haematocoele, an old left ampul- thosethose who have been exempted. lary abortion, and a peritubal haematoma were Dr Hicks also refers to "the clinical assessfound. After a left salpingectomy and peri- ment TRAB." The assessment to which he toneal toilet she made a satisfactory recovery refers,ofhowever, the clinical attachment and is now well established on oral contracep- scheme introducedis by the Department of tives. Although HERBERT E REISS Health and Social Security in 1966. that this the GMC originally suggested London NW1 scheme should be linked to the TRAB tests, the agreement of the profession was not I Yacoub, T, 1977. In press. forthcoming to this proposal and the scheme does not and never has formed part of the Flap lacerations test. Dr Hicks's comment on "the lack of congruency between the written and the SIR,-Your leading article (7 January, p 4) practical parts of the test" is therefore based is misleading on an important point-namely, on a false assumption. that in our treatment of flap lacerations M R DRAPER Registrar, unlimited walking is allowed from the day of Medical Council General injury and not, as you suggest, from the time London WI of wound healing.

given that RHA chairmen were not gravely concerned at the implications of the draft terms as they now stand. Each chairman must express his views for himself. I would summarise my own fears in this way: it has been observed that a timesensitive contract of the kind under negotiation is more akin to an industrial, work-based, non-professional arrangement than anything previously contemplated. The summary of the proposals which you published (10 December, p 1558), including that for the proposed basic time commitment and additional half-days, does not appear necessarily to conflict with this view. It seems to me therefore that all of us (authorities, Department of Health and Social Security, and BMA members) will wish to be satisfied before their adoption that the implications of what may be a radical departure from traditional standards are fully understood and are widely accepted as desirable and workable without undue bureaucratic supervision. I understand it is accepted in industry that a necessary precondition of a time-sensitive contract is that management must be entitled to stipulate in considerable detail precisely what work is to be done, by whom, when, and for how long. It must therefore be a matter of anxious consideration for us all what this industrial concept of clocking in and clocking out may imply for the Health Service and whether it could require modification of previous concepts of professional status and standards. As I told Mr D E Bolt at the meeting, I am sure my colleagues and I will be extremely anxious to avoid a situation where irksome administrative checks (with or without the appointment of detailed medical budget holders) become necessary in the NHS. So far from welcoming such control most authorities would regard their avoidance as a paramount priority if other ways can be found of protecting patients' and the public's interests. If the suggested contract is adopted my fear is that this may not always be possible. In his letter Dr Cameron also mentions that the primacy of the whole-time commitment was not raised by regional chairmen at the meeting. This is correct. Time was short, and, understandably, much of it was taken up by a summary of the BMA position. Although this is not the place to rehearse the arguments in favour of the whole-time commitment, it should be made clear that regional chairmen did not raise the matter again only because the Secretary of State himself had just done so. KINGSLEY WILLIAMS Chairman,

B S CRAWFORD M GIPsoN New consultant contract Plastic and Jaw Department, Royal Hospital Annexe, Fulwood, Sheffield

Heart disease and the cyclist SIR,-I was interested to read the short paper by Dr H K Robertson on heart disease in lifelong cyclists (24-31 December, p 1635). His findings would have been reassuring to Dr George Herschell, senior physician to the National Hospital for Diseases of the Heart, who wrote a paper in 1896 on "Cycling as a cause of heart disease."' Dr Herschell wrote, "When we allow a child to ride long distances on a cycle we are carrying out a physiological experiment which, although

SIR,-As one of the five chairmen of regional health authorities present at the meeting with the Secretary of State and consultants' negotiators on 30 November, may I comment on the references to our views by the Chairman of the BMA Council in his letter to Mr Ennals of 5 December (17 December, p 1615) ? In his letter Dr Cameron says that apart from the financial consequences of the proposed new contract none of the anxieties expressed by RHA chairmen were fundamental criticisms of it and none would justify a significant change. While Dr Cameron and the consultants' negotiators must make their own judgment of the proposals, it would be unfortunate if the impression were to be

Wessex Regional Health Authority

Winchester, Hants

***The Secretary writes: "Mr Kingsley Williams may not realise that it is 11 years since the BMA first publicly warned that the concept of 'whole-time' service might have to be abandoned and replaced by a closed contract of 10 notional half-days (British Medical3Journal Supplement, 1967, 2, 93). "In this letter he goes into greater detail than, apparently, did the discussion with the Secretary of State. The concept of 'clocking in and out' would be even more repugnant to the profession than to authorities-and it was never envisaged. It is fundamental to the new contract that it should be based on the same flexible interpretation of notional half-day sessions which already exists. What cannot

The Progestasert and ectopic pregnancy.

178 of this nature. The whole article is inclined towards conservative treatment, but there is no conservative treatment for a paraoesophageal hernia...
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