ABDOMINAL WOUND DISRUPTION

ABDOMINAL WOUND DISRUPTION

237 THE NOTTINGHAM MEDICAL SCHOOL MR,—i thmk most anatomists would agree that to teach the structure of the human body from dissections and models one...

174KB Sizes 2 Downloads 70 Views

237 THE NOTTINGHAM MEDICAL SCHOOL MR,—i thmk most anatomists would agree that to teach the structure of the human body from dissections and models one day a week for three terms is a complete waste of time for students and staff alike. It is therefore a pity that Sir George Pickering and his committee had not the courage of their convictions and did not recommend a preclinical course for Nottingham University which omitted all instruction in anatomy. There is no doubt that this would produce a new type of recruit to our profession, able to leap with agility from the base to the helix of the D.N.A. molecule, discourse fluently on valency forces, predict accurately the behaviour of brown rats to given parameters, and produce beautiful statistics for the Minister of Health. Presumably Sir George and his committee intend that the medical graduates of the future will not be required to personally examine their patients, for to them such a procedure would be meaningless. Furnished with a syndrome our scientific medicals would be able to determine what further tests were necessary, to analyse and quantify the results, and so to arrive at diagnosis and treatment. This could all be done objectively from office or laboratory without the embarrassment or subjective irrelevance of personal encounter between patient and doctor. Are Sir George and his committee convinced that this is the kind of service the public wish to have from the National Health Service ? Medical history here repeats itself. Despite the discoveries of Vesalius and other medieval anatomists, it is not so long ago in terms of anatomical time that Sir George’s predecessors in the Royal College of Physicians ascribed all the ills that beset humanity to the influence of the stars, the position of the moon, or the last encounter with a black cat, and prescribed the liver of a toad ". Perhaps the nosology of the physicians of tomorrow will centre on planetogeny, cosmo-chemistry, and esobiology. A surgical colleague serving on Sir George’s committee once remarked to me that surgeons need know no anatomy, and that operations would then be adventures in exploration -whether for patient or surgeon he did not specify. After all it is but a few months since one of our legal authorities ruled that while to remove the liver in mistake for the kidney was regrettable, it could not be regarded as " failure to exercise due skill and care ". I wonder who amongst us would decide to take his car for repairs to a garage employing only graduate mechanics, highly intelligent about the theory of explosive forces in general, but with no knowledge of the practical construction of car engines ? Is it not time that the common man who pays for all this should be invited to say what he expects from his doctor ? Does he expect his doctor to be able to examine a joint and say what is wrong with it ? Does he expect his doctor to be able to relate the swelling that he fears to the anatomical parts ? Does he expect an explanation from his doctor of the location and distribution of the pain that keeps him awake at night ? If so, is the best training to meet these demands a knowledge of the behaviour of the rat, of the structure of the D.N.A. molecule, and of all the other " bios " seeking so eagerly to attach to medicine, rather than a knowledge of the normal structure of the human body ? In this respect perhaps a fitting task for the medical graduates of our new medical schools would be a doorto-door survey asking just these questions. The answers could then be programmed for the computers, by that time a must " for all medical schools, and an additional charge on the taxpayer. Anatomy Department, The University, G. M. WYBURN. Glasgow, W.2. "

"

The suture material that I have used, however, has been monofilament stainless-steel wire. I feel that this material may have one advantage over the braided nylon material that he has used. Steel, apparently, can safely be buried without too great a fear of persistent sinuses if infection occurs. I have seen stainless-steel sutures exposed in the bottom of wounds bathed in faeces. These wounds have gone on to heal permanently over the sutures without sinus formation or subsequent recurrent infection. Department of Surgery, Albert Einstein College of Medicine, Yeshiva University, ROBERT W. M. FRATER. New York, 61, N.Y.

ABNORMAL CELLS IN CEREBROSPINAL FLUID SIR,-Dr. Adams and Dr. Connor (July 17) inquire whether others have seen cells in mitosis in the cerebrospinal fluid in inflammatory conditions. This has, in fact, been described and illustrated (see fig. 44 in Sayk’smonograph, fig. 4 in the paper by Bots et al.,2 and fig. 7 Fanconi 3). In samples with a high proportion of the plasmocyte series, I have sometimes found a number of mitotic figures without any long search. Exactly the same thing is seen in pleural fluid,4 and in concentrates of white cells from peripheral blood.5 In the light of present knowledge about the cellular production of free antibody, it seems highly likely that these are lymphoid cells in the process of hypertrophy and multiplication in response to an antigenic stimulus. Laboratory of Clinical Cytology, Churchill Hospital, A. I. SPRIGGS. Oxford.

"

"

ABDOMINAL WOUND DISRUPTION SIR,-Mr. Efron’s article was timely and covered the subject extremely well. I have no doubt about the value of the one-layer closure, and with its use my own experience agrees with his in showing a definite reduction in the incidence of disruption.

TETRACYCLINES IN TUMOUR TISSUES SIR,-In 1957 Rall et al. demonstrated that tetracycline, chlortetracycline, and oxytetracycline tend to localise and persist in tumour tissue. Klinger and Katzmade use of this fact in the fluorescence test for gastric carcinoma. It has occurred to me that, by suitable substitution in the tetracycline molecule, alkylating agents such as the nitrogen rnustards might be made more specific anti-tumour agents. I would be interested to learn if anyone has any information on the subject. Royal Air Force Hospital, Uxbridge, Middlesex.

F. R. JONES.

SEVERE EPISTAXIS Frew SIR,-Mr. (July 17) mentions in his earlier treatment of epistaxis " cautery, sedation, or packing " and " the usual aids to reduce haemorrhage—i.e., vitamin K, adrenoxyl, and various Since his cases all nasal sprays containing adrenaline ". presented with slight bleeding, their early treatment is of interest. No doubt " i.e." would have better read " e.g.", but I can add a little to the conventional first-aid. Most nurses lay the patient supine, and put cold packs on the bridge of the nose. The first procedure merely allows swallowing and inhalation, and the second dilutes the blood and prevents clotting. I remove all packs, sit the patient up, head forward, and put a finger firmly on the affected side of the nose for about ten minutes. Previously uncontrollable bleeding usually stops for good, and failure is my usual but rare indication for reference to a surgeon. Whether this method acts by compressing the commoner bleeding points, by encouraging clotting in a pool of blood, or by inhibiting sneezing, I have no firm views-the method is empirical. Other specific measures than Mr. Frew’s are possible. Thrombin Topical ’, useful in miscellaneous superficial 1. 2. 3. 4. 5. 6. 7.

Sayk, J. Cytologie der Cerebrospinalflussigkeit. Jena, 1960. Bots, G. T. A. M., Went, L. N., Schaberg, A. Ned. Tijdschr. Geneesk. 1963, 107, 445. Fanconi, G. Ergebn. inn. Med. Kinderheilk. 1939, 57, 399. Spriggs, A. I. The Cytology of Effusions; see fig. 9. London, 1957. Alexander, R. F., Spriggs, A. I. J. Clin. Path. 1960, 13, 414; see fig. 2. Rall, D. P., Loo, T. L., Lane, M., Kelly, M. G. J. natn. Cancer Inst. 1957, 19, 79. Klinger, J., Katz, R. Gastroenterology, 1961, 41, 29.