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A SURGICAL POLICY FOR PEPTIC ULCER
395
Wheatley’s suggestion that penicillin and streptomycin should be applied locally. Topical streptomycin is particularly liable to produce skin reactions, and topical penicillin is not free from the same disadvantage. I have not yet seen a skin reaction with chloramphenicol. 5% chloramphenicol in propylene glycol is not expensive ; 100-150 applications cost 8s., if the solution is made up in one’s own dispensary. The total cost in antibiotics of treating a case of paronychia was 3s. 7d.; Dr.
it is now less. Mr. Jones’s investigation of seasonal variations (Jan. 31) interested me greatly. I agree there are so many factors that it is difficult to prove anything. I have, however, taken from last year’s records on septic hands (976 cases) a few figures which may be relevant. In the months January, February, March, October, November, and December, 58 cases of common septic hand conditions took over a fortnight to heal, 21 over three weeks, and 10 over a month. In the months April-September the corresponding figures were 26, 10, and 4. The figures for paronychia were : over a fortnight, in the winter 18 and in the summer 4 ; over three weeks, in the winter 4 and in the summer nil; over a month, in the winter 2 and in the summer nil. It is the clinically resistant cases that we hope to abolish. Some, as I have shown, are due to bacteriological resistance, and chloramphenicol will help. Many are due to faulty surgery in the first place, and bacteriological resistance is acquired secondarily. Paronychia is the first septic condition of the hand in which penicillinresistant organisms have been noted in significant numbers on first attendance at the clinic. This casualty appointment, like many others, has been unfilled for some time ; and in the past year no less than seventeen housemen have been detailed, at one time or another, to operate on the cases. Under such conditions it is impossible to maintain a consistently high standard. Nevertheless the 230 cases of paronychia treated since the principles I adopted have been emphasised, have had an average duration of treatment of 7-11 days. This is nearly a 40% improvement on anything we have had before, and exactly half the average disability in 1950. Royal Infirmary, Sunderland.
T. G. LOWDEN.
A SURGICAL POLICY FOR PEPTIC ULCER
SIR,-May I congratulate Mr. Orr and Mr. Daintree Johnson on their excellent article in your issue of Feb. 7 ? They have recognised the surgeon’s dilemma : excellent as ulcer surgery is, a fairly high resection is necessary for sure relief, and the higher one goes the more likely one is to encounter untoward effects (of which we have seen examples from all over the country). The authors’ plan of operation is designed to secure the benefits of gastric surgery without its disadvantages. In my own clinic we treated a small series of patients by limited gastrectomy with vagotomy, and we were well pleased with the results, but we are waiting a little longer before going on. Meanwhile, we are giving an extended trial to another promising procedure, the results of which have not yet been assessed for publication. These latest figures from Mr. Orr and Mr. Johnson are a strong encouragement to us to begin a second series of limited gastrectomy with vagotomy in suitable cases. It is only from the most careful personal analysis of an adequate series of cases such as this, that any, deductions can be The authors mention ’ drawn. important that they have also had access to a second series, operated upon by a colleague. I should like to emphasise the value of this method in which the same observer takes stock of both series and can therefore safelv draw comparisons. We also have made a start in this direction, and we hope soon to extend similar inquiries much more
widely.
Finally, may I voice one criticism ? I believe they are wrong in supposing that even the most cunning questionnaire is as good as an interview : for example, the signs of riboflavine deficiency have to be looked for if they are not to be missed. Moreover, patients who have, through surgery, been relieved of their life-long ulcer pains are often reluctant, unless pressed, to admit to even so gross a feature as bilious vomiting, and, moreover, they often mistake bile for food. In this article, the incidence of bilious vomiting is about " right," but that of the vomiting of food seems to me too high. Department of Surgery, University of Liverpool.
CHARLES WELLS.
METHOD OF ADMINISTERING DICOUMAROL
SiR,-The paper by Dr. Bjerkelund (Feb. 7) was very interesting to us here as, for some years, the determination of prothrombin levels and the task of working out further dosages of dicoumarol or of ethyl biscoumacetate (’ Tromexan ’) has been entrusted to the biochemist. This arose because the requests were often inscribed" please advise dosage of anticoagulant," and also because we found commonly that inexperienced housemen either were reluctant to order enough dicoumarol or ordered excessive amounts. Furthermore, daily prothrombin estimations were becoming a burden to both staff and patients. Consequently the following scheme was devised : The
initial any determined by
including
request form contains full clinical details,
dosage already given.
The
prothrombin
is
Quick’s one-stage method using rabbit-brain
thromboplastin, and the result is reported as the index and corresponding percentage normal. This is written direct on to the request form together with dosage details for the evening of the day of test, the following day or days, and the morning of the next test day. The form then goes back to the ward ; or in the case of outside hospitals in the group the report is telephoned. Usually tests are done every other day-chiefly Mondays, Wednesdays, and Fridays. The
advantages
are
briefly :
1. The report gets to the ward quickly and treatment can be started with little delay. 2. There is no laboratory office work except to note incoming requests in the day-book ; there is no typing (to save technical time, the report is written within a rubber-stamp framework), and we keep our own record of the dosages in the laboratory prothrombin-time book. 3. Tests are necessary only every other day. 4. In the case of ethyl biscoumacetate, the dosages are divided into morning and evening tablets, and usually one 300 mg. tablet is given at 6 A.M. on the day of test to maintain a satisfactory level until the result of the test is known. 5. Whilst it might be argued that it is unwise to leave the dosage to the laboratory, in practice this works very well ; for the biochemist, unlike the houseman who has many such drug dosages to work out, can bring a fresh mind to the problem. Furthermore, it is obviously an asset to have someone who has been concentrating on this dosage problem for several years and who has the patient’s previous figures at his finger-tips. Indeed, provided full clinical details are given, it is possible for the laboratory to point out the inadvisability of starting a course of ethyl biscoumacetate in, for example, pregnancy, if this has been overlooked by the clinicians. 6. General practitioners are more ready to treat their own patients instead of admitting them to hospital. In the case of ambulant patients the blood is taken by the laboratory, the result and dosage telephoned to the doctor, and the dosage alone telephoned to the patient. The doctor then has merely to check the clinical side every other day. He knows what dosage the patient has been instructed to take, and can alter it if he considers this necessary. This is surely a good example of a general practitioner receiving immediate and full cooperation from a hospital department and yet maintaining full control of the patient. 7. Only two cases of major h2emorrhage in the past four One was in the early days, through years can be recollected. too infrequent testing, and was controlled by transfusion.
Wheatley’s suggestion that penicillin and streptomycin should be applied locally. Topical streptomycin is particularly liable to produce skin reactions, and topical penicillin is not free from the same disadvantage. I have not yet seen a skin reaction with chloramphenicol. 5% chloramphenicol in propylene glycol is not expensive ; 100-150 applications cost 8s., if the solution is made up in one’s own dispensary. The total cost in antibiotics of treating a case of paronychia was 3s. 7d.; Dr.
it is now less. Mr. Jones’s investigation of seasonal variations (Jan. 31) interested me greatly. I agree there are so many factors that it is difficult to prove anything. I have, however, taken from last year’s records on septic hands (976 cases) a few figures which may be relevant. In the months January, February, March, October, November, and December, 58 cases of common septic hand conditions took over a fortnight to heal, 21 over three weeks, and 10 over a month. In the months April-September the corresponding figures were 26, 10, and 4. The figures for paronychia were : over a fortnight, in the winter 18 and in the summer 4 ; over three weeks, in the winter 4 and in the summer nil; over a month, in the winter 2 and in the summer nil. It is the clinically resistant cases that we hope to abolish. Some, as I have shown, are due to bacteriological resistance, and chloramphenicol will help. Many are due to faulty surgery in the first place, and bacteriological resistance is acquired secondarily. Paronychia is the first septic condition of the hand in which penicillinresistant organisms have been noted in significant numbers on first attendance at the clinic. This casualty appointment, like many others, has been unfilled for some time ; and in the past year no less than seventeen housemen have been detailed, at one time or another, to operate on the cases. Under such conditions it is impossible to maintain a consistently high standard. Nevertheless the 230 cases of paronychia treated since the principles I adopted have been emphasised, have had an average duration of treatment of 7-11 days. This is nearly a 40% improvement on anything we have had before, and exactly half the average disability in 1950. Royal Infirmary, Sunderland.
T. G. LOWDEN.
A SURGICAL POLICY FOR PEPTIC ULCER
SIR,-May I congratulate Mr. Orr and Mr. Daintree Johnson on their excellent article in your issue of Feb. 7 ? They have recognised the surgeon’s dilemma : excellent as ulcer surgery is, a fairly high resection is necessary for sure relief, and the higher one goes the more likely one is to encounter untoward effects (of which we have seen examples from all over the country). The authors’ plan of operation is designed to secure the benefits of gastric surgery without its disadvantages. In my own clinic we treated a small series of patients by limited gastrectomy with vagotomy, and we were well pleased with the results, but we are waiting a little longer before going on. Meanwhile, we are giving an extended trial to another promising procedure, the results of which have not yet been assessed for publication. These latest figures from Mr. Orr and Mr. Johnson are a strong encouragement to us to begin a second series of limited gastrectomy with vagotomy in suitable cases. It is only from the most careful personal analysis of an adequate series of cases such as this, that any, deductions can be The authors mention ’ drawn. important that they have also had access to a second series, operated upon by a colleague. I should like to emphasise the value of this method in which the same observer takes stock of both series and can therefore safelv draw comparisons. We also have made a start in this direction, and we hope soon to extend similar inquiries much more
widely.
Finally, may I voice one criticism ? I believe they are wrong in supposing that even the most cunning questionnaire is as good as an interview : for example, the signs of riboflavine deficiency have to be looked for if they are not to be missed. Moreover, patients who have, through surgery, been relieved of their life-long ulcer pains are often reluctant, unless pressed, to admit to even so gross a feature as bilious vomiting, and, moreover, they often mistake bile for food. In this article, the incidence of bilious vomiting is about " right," but that of the vomiting of food seems to me too high. Department of Surgery, University of Liverpool.
CHARLES WELLS.
METHOD OF ADMINISTERING DICOUMAROL
SiR,-The paper by Dr. Bjerkelund (Feb. 7) was very interesting to us here as, for some years, the determination of prothrombin levels and the task of working out further dosages of dicoumarol or of ethyl biscoumacetate (’ Tromexan ’) has been entrusted to the biochemist. This arose because the requests were often inscribed" please advise dosage of anticoagulant," and also because we found commonly that inexperienced housemen either were reluctant to order enough dicoumarol or ordered excessive amounts. Furthermore, daily prothrombin estimations were becoming a burden to both staff and patients. Consequently the following scheme was devised : The
initial any determined by
including
request form contains full clinical details,
dosage already given.
The
prothrombin
is
Quick’s one-stage method using rabbit-brain
thromboplastin, and the result is reported as the index and corresponding percentage normal. This is written direct on to the request form together with dosage details for the evening of the day of test, the following day or days, and the morning of the next test day. The form then goes back to the ward ; or in the case of outside hospitals in the group the report is telephoned. Usually tests are done every other day-chiefly Mondays, Wednesdays, and Fridays. The
advantages
are
briefly :
1. The report gets to the ward quickly and treatment can be started with little delay. 2. There is no laboratory office work except to note incoming requests in the day-book ; there is no typing (to save technical time, the report is written within a rubber-stamp framework), and we keep our own record of the dosages in the laboratory prothrombin-time book. 3. Tests are necessary only every other day. 4. In the case of ethyl biscoumacetate, the dosages are divided into morning and evening tablets, and usually one 300 mg. tablet is given at 6 A.M. on the day of test to maintain a satisfactory level until the result of the test is known. 5. Whilst it might be argued that it is unwise to leave the dosage to the laboratory, in practice this works very well ; for the biochemist, unlike the houseman who has many such drug dosages to work out, can bring a fresh mind to the problem. Furthermore, it is obviously an asset to have someone who has been concentrating on this dosage problem for several years and who has the patient’s previous figures at his finger-tips. Indeed, provided full clinical details are given, it is possible for the laboratory to point out the inadvisability of starting a course of ethyl biscoumacetate in, for example, pregnancy, if this has been overlooked by the clinicians. 6. General practitioners are more ready to treat their own patients instead of admitting them to hospital. In the case of ambulant patients the blood is taken by the laboratory, the result and dosage telephoned to the doctor, and the dosage alone telephoned to the patient. The doctor then has merely to check the clinical side every other day. He knows what dosage the patient has been instructed to take, and can alter it if he considers this necessary. This is surely a good example of a general practitioner receiving immediate and full cooperation from a hospital department and yet maintaining full control of the patient. 7. Only two cases of major h2emorrhage in the past four One was in the early days, through years can be recollected. too infrequent testing, and was controlled by transfusion.