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FATALITY FROM THREE COMMON SURGICAL CONDITIONS IN TEACHING AND NON-TEACHING HOSPITALS
1175 pay of such a post is not sufficient for an experienced doctor with family responsibilities. Each of us knows a few middle-aged doctors with wide experience and good judgment who have not been able to acquire higher qualifications but would like to work in hospitals permanently, provided they are assured of security and a reasonable income. At the present time they must drift away into jobs where their experience is useless or even become unemployed. I therefore consider that the quality of medical care to the public could be improved by the creation of the post of a senior casualty officer at each peripheral hospital with a salary of perhaps E1500 yearly. F. R. ZADIK. HISTAMINE AND DENTAL CARIES
SiR,-Severe earache from carious lower teeth is uncommon, and very often
not
seek an otologist’s I have quickly relieved
patients
advice rather than a dentist’s. bad toothache in many patients (including myself) by a carious cavity with histaminic powder. Histamine has not, as far
filling cause
might
chlorpheniramine,
an
anti-
as know, been cited as a of dental caries, but my results suggest that this be a fruitful hypothesis for research by dentist
I
gnil nathnlnoi-t
C. NIOSI.
by the body as to
constitute a sound barrier to organisms, then the surgeon has no right to interfere. Not uncommonly the reromesenteric appendix is overlooked ; the initial symptoms of diarrhoea and vomiting, with little or no guarding in the right iliac fossa, are too often ascribed to gastroenteritis, and it is only when the initial sealing-off process breaks down that the patient reaches hospital and quite a mess is found at operation. I have not read in the textbooks that headache is rarely a symptom of appendicitis. Headache is very, very rare with appendicitis, and if the patient complains of headache one ought to examine the remainder of the body for the cause of the abdominal pain, and only as a last resort make a diagnosis of appendicitis. Of perforations, I would again say " suture the hole as early as possible." Reviews of cases treated conservatively often contain an example of a " disaster "-it is fear of this possibility of an error in diagnosis which makes me decide in the vast majority of cases to operate. Most of the " perforations " I have lost have died through some other factor which would have killed them anyway—e.g., a man, aged 27 years, with two gastric ulcers, and a liver riddled with secondaries from a carcinoid tumour (unsuspected until the liver was seen at
operation). I consider that in hyperplasia of the prostate the bedside appreciation of each patient is of paramount importance. These people (I refer particularly to the patient admitted as an emergency with retention) are elderly, in a poor state of health, and poor operative risks. Adequate appreciation of the length of the history of urinary trouble, the cardiovascular
system, and the blood-urea are to my mind the three essentials, the state of the tongue ! High-powered kidney-function an unnecessary discomfort and risk to the patient. Catheterisation is to be avoided, and if the patient is judged fit for operation, the prostate should be removed on the day of admission. My preference is for a simple Freyer’s enucleation as quickly and gently as possible, no tipping of the patient, closing the bladder whenever possible, relying on a gum-elastic catheter for drainage, and getting the patient back to bed and round from the anaesthetic as soon as possible, bearing in mind that moving the patient from the operating-table on to the trolley and into bed is what shakes him up as much as the operation itself. Age is no bar to operation if other things are equal, and an optimistic outlook by the surgeon, plus real sympathy for their particular discomforts, is of more value to these elderly people than some may realise. Weymouth and District Hospital, M. E.
plus FATALITY FROM THREE COMMON SURGICAL CONDITIONS IN TEACHING AND NON-TEACHING HOSPITALS
SIR,-The statistical review by Dr. Lee and his colleagues (Oct. 19) prompts me to make certain comments from the viewpoint of a registrar at a non-teaching hospital. I was surprised to learn that the mortality-rates for the three conditions reviewed were so high, and I felt a little dubious about accepting the figures quoted. To my mind, the mortality-rate for a certain surgical condition is found by quoting the total number of patients treated and the total number who died. No " sampling " elimination is allowable if a worthwhile estimate is to be obtained. Having kept records of the cases on which I have operated, I can quote the following mortalityrates: appendicectomies 0.56%, perforations 7%, prostatectomies 5.4%. Overall mortality-rates will always depend on the direct personal supervision of the surgeon concerned, and it is my contention that one surgeon can only look after, with the maximum efficiency, a certain number of patients. Reliance on telephone messages from subordinates is not sufficient—it is on personal appreciation of the case at the bedside that the best decision for any or
particular When
treatment
depends.
diagnosis of appendicitis is made, take out the appendix, no matter what the hour. Very few patients with appendicitis can safely be left for a few hours, until it is more convenient for all concerned to operate. Reliance on pulse and temperature is to be condemned-a man may have generalised peritonitis with a temperature of 98.2° and a pulse-rate of 70 a minute, and still not look ill. Where there are a capable surgeon and adequate facilities for operation, the conservative treatment of appendicitis is not, in my view, to be recommended. If those advocates of this method of treatment were asked now they themselves would like to be treated for appendicitis, how many would truthfully choose their own method ? I regard a paramedian incision as far better than the gridiron ; it is easier to make and easier to extend if required, and gives more adequate access to the other organs if the diagnosis is wrong ; and one does not (or should not) get hernise through it—this from one who has spent some hours repairing incisional herniæ through other people’s "gridirons"! The charge that one is violating " clean territory " to my mind is unacceptable. If an appendix is so securely walled off a
tests are
Dorset.
JOHN
JEWERS.
THE CUP THAT CHEERS
often allied with " nerves" and is garrulity, among the commoner acquaintances of the general practitioner." Nine consecutive patients of mine all complaining of causeless " insomnia, were drinking daily from 5 to 10 cups of tea (or coffee) each. The actual amount was fairly constant day by day in each person, and little or none was drunk after teatime. Four of these patients found that their insomnia ceased when they gave up tea-drinking. It is a commonplace that tea taken in the evening may cause sleeplessness, but it also appears that in some persons tea taken much earlier in the day may still be acting as a cerebral stimulant at bedtime. One wonders whether the vast national demand for barbiturates and tranquillisers does not in part arise from the national cerebral intoxication with caffeine. Chronic hypochromic anaemia is also always with us. If ferrous gluconate is added to a cup of tea, the inky appearance proclaims the formation of ferrous tannate. Although the inky colour is abolished by acidification, the addition of alkali (to simulate conditions in the small bowel) restores it. May it not be that a large part of our iron mixtures arrives at the duodenal mucosa in this-presumably unassimilable-form 1 It is indeed rather difficult to understand how people who take tea or coffee with every meal ever absorb iron from their food at all. N. B. EAST-WOOD.
SiR,-Insomnia,
actually
SiR,-Severe earache from carious lower teeth is uncommon, and very often
not
seek an otologist’s I have quickly relieved
patients
advice rather than a dentist’s. bad toothache in many patients (including myself) by a carious cavity with histaminic powder. Histamine has not, as far
filling cause
might
chlorpheniramine,
an
anti-
as know, been cited as a of dental caries, but my results suggest that this be a fruitful hypothesis for research by dentist
I
gnil nathnlnoi-t
C. NIOSI.
by the body as to
constitute a sound barrier to organisms, then the surgeon has no right to interfere. Not uncommonly the reromesenteric appendix is overlooked ; the initial symptoms of diarrhoea and vomiting, with little or no guarding in the right iliac fossa, are too often ascribed to gastroenteritis, and it is only when the initial sealing-off process breaks down that the patient reaches hospital and quite a mess is found at operation. I have not read in the textbooks that headache is rarely a symptom of appendicitis. Headache is very, very rare with appendicitis, and if the patient complains of headache one ought to examine the remainder of the body for the cause of the abdominal pain, and only as a last resort make a diagnosis of appendicitis. Of perforations, I would again say " suture the hole as early as possible." Reviews of cases treated conservatively often contain an example of a " disaster "-it is fear of this possibility of an error in diagnosis which makes me decide in the vast majority of cases to operate. Most of the " perforations " I have lost have died through some other factor which would have killed them anyway—e.g., a man, aged 27 years, with two gastric ulcers, and a liver riddled with secondaries from a carcinoid tumour (unsuspected until the liver was seen at
operation). I consider that in hyperplasia of the prostate the bedside appreciation of each patient is of paramount importance. These people (I refer particularly to the patient admitted as an emergency with retention) are elderly, in a poor state of health, and poor operative risks. Adequate appreciation of the length of the history of urinary trouble, the cardiovascular
system, and the blood-urea are to my mind the three essentials, the state of the tongue ! High-powered kidney-function an unnecessary discomfort and risk to the patient. Catheterisation is to be avoided, and if the patient is judged fit for operation, the prostate should be removed on the day of admission. My preference is for a simple Freyer’s enucleation as quickly and gently as possible, no tipping of the patient, closing the bladder whenever possible, relying on a gum-elastic catheter for drainage, and getting the patient back to bed and round from the anaesthetic as soon as possible, bearing in mind that moving the patient from the operating-table on to the trolley and into bed is what shakes him up as much as the operation itself. Age is no bar to operation if other things are equal, and an optimistic outlook by the surgeon, plus real sympathy for their particular discomforts, is of more value to these elderly people than some may realise. Weymouth and District Hospital, M. E.
plus FATALITY FROM THREE COMMON SURGICAL CONDITIONS IN TEACHING AND NON-TEACHING HOSPITALS
SIR,-The statistical review by Dr. Lee and his colleagues (Oct. 19) prompts me to make certain comments from the viewpoint of a registrar at a non-teaching hospital. I was surprised to learn that the mortality-rates for the three conditions reviewed were so high, and I felt a little dubious about accepting the figures quoted. To my mind, the mortality-rate for a certain surgical condition is found by quoting the total number of patients treated and the total number who died. No " sampling " elimination is allowable if a worthwhile estimate is to be obtained. Having kept records of the cases on which I have operated, I can quote the following mortalityrates: appendicectomies 0.56%, perforations 7%, prostatectomies 5.4%. Overall mortality-rates will always depend on the direct personal supervision of the surgeon concerned, and it is my contention that one surgeon can only look after, with the maximum efficiency, a certain number of patients. Reliance on telephone messages from subordinates is not sufficient—it is on personal appreciation of the case at the bedside that the best decision for any or
particular When
treatment
depends.
diagnosis of appendicitis is made, take out the appendix, no matter what the hour. Very few patients with appendicitis can safely be left for a few hours, until it is more convenient for all concerned to operate. Reliance on pulse and temperature is to be condemned-a man may have generalised peritonitis with a temperature of 98.2° and a pulse-rate of 70 a minute, and still not look ill. Where there are a capable surgeon and adequate facilities for operation, the conservative treatment of appendicitis is not, in my view, to be recommended. If those advocates of this method of treatment were asked now they themselves would like to be treated for appendicitis, how many would truthfully choose their own method ? I regard a paramedian incision as far better than the gridiron ; it is easier to make and easier to extend if required, and gives more adequate access to the other organs if the diagnosis is wrong ; and one does not (or should not) get hernise through it—this from one who has spent some hours repairing incisional herniæ through other people’s "gridirons"! The charge that one is violating " clean territory " to my mind is unacceptable. If an appendix is so securely walled off a
tests are
Dorset.
JOHN
JEWERS.
THE CUP THAT CHEERS
often allied with " nerves" and is garrulity, among the commoner acquaintances of the general practitioner." Nine consecutive patients of mine all complaining of causeless " insomnia, were drinking daily from 5 to 10 cups of tea (or coffee) each. The actual amount was fairly constant day by day in each person, and little or none was drunk after teatime. Four of these patients found that their insomnia ceased when they gave up tea-drinking. It is a commonplace that tea taken in the evening may cause sleeplessness, but it also appears that in some persons tea taken much earlier in the day may still be acting as a cerebral stimulant at bedtime. One wonders whether the vast national demand for barbiturates and tranquillisers does not in part arise from the national cerebral intoxication with caffeine. Chronic hypochromic anaemia is also always with us. If ferrous gluconate is added to a cup of tea, the inky appearance proclaims the formation of ferrous tannate. Although the inky colour is abolished by acidification, the addition of alkali (to simulate conditions in the small bowel) restores it. May it not be that a large part of our iron mixtures arrives at the duodenal mucosa in this-presumably unassimilable-form 1 It is indeed rather difficult to understand how people who take tea or coffee with every meal ever absorb iron from their food at all. N. B. EAST-WOOD.
SiR,-Insomnia,
actually