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BILLROTH AND CARDIAC SURGERY
250 one injection of pethidine and chlorpro(50 mg. each) was given in 24 hours (temperature range 305-32°C), and this probably more for my own peace of mind than for the patient’s temperature control.
patient in whom only mazine
I would suggest that a progressive reduction in the dose of drugs required for the control of hypothermia is indicative either of adequate temperature control or of a diminishing response to cold by the patient-i.e., deterioration, not improvement. The converse-namely, that an increase in or a failure to reduce the dose of drugs indicates inadequate temperature control-is not necessarily true, but may reflect the level at which temperature control is aimed. Thus at around 33°C, particularly in the conscious patient, shivering may be prominent, temperature control difficult, and the drug dosage remain constantly large; but at 30-32°C the shivering response to cold is greatly diminished, temperature control is easier to maintain, and the dose of druss reauired is smaller. St.
Department of Neurosurgery, George’s Hospital, London, S.W.1.
MAURICE BLOCH.
CYTOLOGY OF THE CERVIX SIR,-May I comment on two letters in your issue of
July 27 ? Dr. Spriggs
seeks to convert me, but I am already half his side. He advocates cone biopsy for carcinoma-insitu, and screening at intervals of three to five years: I agree with both. Where I differ is on the issue of canvassing for healthy women to have the test, in the present state of our knowledge; but even here his proposition that " we should foster the gradual development of a service " is one to which I could assent. What should be avoided are the emotional overtones and the wholesale
on
hysterectomies. Dr. Parker’s letter is another matter. His statement that " 200 Sussex women to whom we offered a chance of life have died of cancer " has been reported in the local press, under the four-column headline " The 200 Doomed Cancer Victims " and subtitled " They might have lived if doctors had helped with the Parker Plan ". Boyes et al.,2 organising a large and well-planned campaign in British Columbia which has been going on for twelve years, found a drop in incidence of clinically invasive squamous carcinoma from 28-4 per 100,000 in 1955 to 19-7 per 100,000 in 1960. Dr. Parker’s figures are so wildly at variance with this result that I hope he will immediately justify them, or retract them. The false impression which they will otherwise make can do untold
been evolved which is shortly due to come into operation. I should add that diagnostic cervical cytology has been available for hospital patients in this area for the past seven
years.
It should be clear, therefore, that personal feelings have not been the cause of the delay of which Dr. Parker
complains. Royal Sussex County Hospital, Brighton.
R. W. P.
JOHNSON.
CONTROL OF FILARIAL WORMS
SIR,-Inote with interest the comments of Dr. Rabindran (June 15) on allergies provoked by diethylcarbamazine in patients with onchocerciasis. Whatever the mechanism involved, the effect on the patient is such that I have known many refuse diethylcarbamazine (’ Banocide ’) therapy. In my experience, the intense pruritus, dermatitis, oedema, and sometimes adenitis provoked by diethylcarbamazine is not often controlled by anti-histamines to any significant extent, and drugs such as promethazine may merely convert a patient from scratching while awake to scratching in his sleep. The heavily infested native patient seldom seems to benefit from diethylcarbamazine therapy alone, and he may be made to feel much worse. In the new case the drug may be curative, but between these two extremes lie a range of patients: usually the non-native temporary residents of an endemic routine " skin area, in whom the disease is revealed by a snip, or skin snips undertaken because of a trivial patch of dermatitis. These patients are then given a course of diethylcarbamazine, and suffer the attendant miseries of the sideeffects. Significantly, a year or so later, a further course of this drug is given, either because the patient is reinfested, or because he has relapsed, and is again suffering from pruritus. Having seen this cycle repeated many times, one is led to question the logic of such a regimen. More extended trials might be given as an adjunct to the " usual course"of diethylcarbamazine to long-term, intermittent, or continuous low-dosage suppressive therapy, using the drug in doses aimed at reducing the skin microfilaria population to insignificant "
values. Head Office, Cameroons Development Corporation, West Cameroon.
J. T. TRENCHAM.
BILLROTH AND CARDIAC SURGERY
apologise for not reacting earlier to two letters 1 2 concerning Billroth and cardiac surgery in which reference is made to our book, Pages in the History of Chest Surgery. SIR,-Ihave
to
There are two remarks of Billroth about cardiac surgery. The first is concerned with pericardial effusion and reads as translated by Mr. Richardson. This remark dates back R. I. K. ELLIOTT. Hove, Sussex. as far as because 1864, Rose,3 Billroth’s successor probably in the chair of of the of Zurich, published University surgery facets which Dr. SiR,—This problem has two distinct a paper on Herztamponade in 1884, in which he writes: " While there is the Parker has confused. On the one hand, in France and Russia many people were saved by personal opinion of individual pathologists as to the already of the pericardium, Billroth-hardly twenty years advisability of starting a scheme for an annual genital paracentesis himself as contemptuously as possible about this ago-expressed check for cancer on all women over 35. On the other operation, this certainly was the general opinion in Germany hand, there are the practical problems involved. at this time." On the one occasion when Dr. Parker approached the The second saying, that a surgeon attempting the suture of a heart should lose the esteem of his colleagues because this group pathologists to discuss his scheme it was pointed out to him that the National Health Service facilities were operation is not compatible with a surgeon’s responsibility, is placed in the year 1881. When Sauerbruch wrote the manunot adequate-if indeed they were entitled to be usedfor such a purpose. Since that time our cytologist has own script of the second volume (1925) of his work Thoracic he asked me to find out the exact source of this numerous occasions discussed with those interested in the Surgery remark. I was unable to find it in Billroth’s own writings scheme the practical possibilities of supplying the services and consequently approached van Eiselsberg, at that time needed in other wavs and a small oilot scheme has in fact
m;"1.rn;pf
1. 2.
Evening Argus, July 26. Boyes, D. A., Fidler, H. K., Lock,
D. R. Brit.
med. J. 1962, i,
203.
1. 2. 3.
Richardson, R. G. Lancet, 1963, i, 1216. Richardson, R. G. ibid. p. 1323. Rose, E. Dtsch. Z. Chir. 1884, 20, 329.
251
professor of surgery at Vienna University, who once wa: Billroth’s assistant. He replied that as far as he rememberec this remark was made by Billroth at a meeting of the Viennf Medical Society before he, von Eiselsberg, became Billroth’! Therefore ir 1881. Sauerbruch’s book 1881 was given as the year of this remark. I regret that Dr. Wilson and I have given a wrong reference by stating that Billroth’s remarks to cardiac surgery are founc in the 1893 edition of his Textbook on General Surgery. Chirurgische Universitätsklinik, RUDOLF NISSEN. Basle, Switzerland.
assistant, approximately in 1880
or
SURGICAL TREATMENT OF PEPTIC ULCERATION SiR,ŁYour leading article1 failed to mention an important point: the conservative operation of vagotomy and pyloroplasty can be recommended to a patient with a duodenal ulcer early in his illness. On the other hand, a gastrectomy, because of its sequelae, can be done only after the patient has suffered a long time-after he has " earned " his gastrectomy. In a recent paper2recommended a gastrectomy only for the " 10 % " of patients in whom the original vagotomy and pyloroplasty has failed. I fully agree with Mr. Burgethat the pyloroplasty must be as thoroughly and adequately done as the vagotomy. I believe, however, that the time needed to do the electrical stimulation test for escaped vagal fibres can be spent better by searching for these fibres. If both the vagotomy and the pyloroplasty are done thoroughly, a gastrectomy can be reserved for the occasional complicated duodenal ulcer. I also do not believe that acid studies should be used in choosing the type of operation for duodenal ulceration. B. J. V. R. DREYER. Cape Town.
investigated as sites of origin of reflex biliary dyskinesia cases presenting with symptoms of cholecystitis and a
in
negative cholecvstoeram. Cape
M. GLASS.
Town.
ACTIVE ALERTED POSTURE SIR In a recent article and in a television interview,i Dr. Joseph, the author of a book on posture,2 asks orthopaedic surgeons three questions: Are there any diseases which you say are due to defects ? Have you treated these cases by changing that
postural person’s
posture ? Has the disease been cured by changing the posture ? The answer, according to him, is No to all three, but according to a number of orthopaedic surgeons whom I have asked the answer is an emphatic Yes.
Dr.
Joseph will probably
agree that
a
person
standing
service at tennis, or to take the ball as a wicket-keeper, is in an alerted position in which all the muscles register some electrical reaction. This is what I have described as " active alerted posture ", in which the average person, with practice, can always learn to be prepared for action.3
ready
to run a race, to
accept
a
weight is carried on the outer side of the foot, the grip the ground, the knees are slightly bent, the abdominal
The toes
muscles are held up and in, the buttocks are held firm with the natal folds compressed, the shoulders are held up and slightly forwards, and the back of the neck is made as long as possible. The muscles are now in balanced contraction at the prime fixing levels. In fact, after long practice the balanced contraction of the muscles produces a perfectly relaxed person. Activating movements can take place at a moment’s notice without fear of putting strain on the muscles or the under-
lying joints. SYMPTOMS OF GALLBLADDER DISEASE WITH A NEGATIVE CHOLECYSTOGRAM
SIR,-The article by Mr. Cronin and Mr. Middleton4 prompts me to report the case of a 45-year-old married woman complaining of frequent, fairly long-continued episodes of nausea, epigastric fullness, stabbing pains under the right intercostal margin associated with a feeling of’tightness, and a dragging sensation in that area on
lying
on
her left side.
Apart from a slight tenderness in the region of her gallbladder, examination, including X-ray of her upper gastrointestinal tract and gallbladder, was negative. She was reassured, was advised to leave off coffee, which seemed to exacerbate her symptoms, and was given a course of ’Bellergal ’ and discharged. She returned six months later with her symptoms unchanged, having meanwhile had a cervical polyp removed and a course of cestogens given without relief. The physical findings were essentially unchanged; but on this occasion a superficial linear fissure about 3 mm. long with hyperasmic margins was noticed at just inside the entrance to the right auditory canal. Since dabbing with 70% alcohol evoked local stinging, the fissure was covered with a swab soaked in 10% cocaine hydrochloride. In five minutes all epigastric discomfort and nausea disappeared, and the patient could be on her left side in complete comfort. Cauterisation of the lesion was followed by complete relief for a year, after which a recurrence of her cholocystic symptoms was again scotched by attention to her right auditory canal-the lesion this time being on the isthmus.
Because I have seen 2 similar cases, I suggest that the territory of the auricular branch of the vagus should be 1. 2. 3.
Lancet, 1963, i, 1087. Dreyer, B. J. v. R. S. Afr. med. J. 1963, 37, 190. Lancet, 1963, i, 1211. 4. Cronin, K., Middleton, M. D. ibid. p. 1392.
Some may think this is an artificial posture, but with practice one can stand actively alerted for as long as eight hours a day, provided that in the other sixteen hours one sits or lies in a chair or bed with the joints held supported in a neutral position. This recumbent position I call " passive supported
posture ". Active alerted posture should be encouraged for low back a person bends forward in what Dr. Joseph describes as normal posture (and which I call " inactive slumping posture ") the weight of the trunk, head, and arms is the activating force. A bending strain is thrown on the lumbosacral joint at the level of the waist, and if in this position a weight is lifted suddenly there is every chance that one of the components of a spinal joint, such as a disc or an apophyseal joint, will be injured. In active alerted posture, when one bends forward there is no break at the lumbosacral level, because the trunk and the pelvis move together. Forward flexion takes place at the hip-joints, in the same way that anyone with a low back disc trouble is advised to pick up objects by bending at his hips and knees. When a jet plane lands its estimated speed is somewhere about 150 m.p.h. and air-brakes are used to keep the plane on the ground; these are propellers driven in reverse to check the forward thrust of the plane. Similarly, in active alerted posture the anterior and lateral abdominal muscles and the posterior spinal muscles are in balanced contraction, and the lumbosacral joint is fixed as in a vice. The result is that when the patient bends forward the trunk and pelvis move as one, and the abdominal muscles act as a brake in the same way as the reversed propellers in the aircraft. Posture has a part in the causation of symptoms of foot strain. There are two functions of the foot-static and dynamic. Sir Arthur Keith and Professor Wood Jones
pain. When
1. 2.
Joseph, J. Family Doctor, 1963, 13, 92. Joseph, J. Man’s Posture: Electromyographic Studies. Springfield, Ill., 1960. 3. Tucker, W. E. Active Alerted Posture. Edinburgh and London, 1960.
patient in whom only mazine
I would suggest that a progressive reduction in the dose of drugs required for the control of hypothermia is indicative either of adequate temperature control or of a diminishing response to cold by the patient-i.e., deterioration, not improvement. The converse-namely, that an increase in or a failure to reduce the dose of drugs indicates inadequate temperature control-is not necessarily true, but may reflect the level at which temperature control is aimed. Thus at around 33°C, particularly in the conscious patient, shivering may be prominent, temperature control difficult, and the drug dosage remain constantly large; but at 30-32°C the shivering response to cold is greatly diminished, temperature control is easier to maintain, and the dose of druss reauired is smaller. St.
Department of Neurosurgery, George’s Hospital, London, S.W.1.
MAURICE BLOCH.
CYTOLOGY OF THE CERVIX SIR,-May I comment on two letters in your issue of
July 27 ? Dr. Spriggs
seeks to convert me, but I am already half his side. He advocates cone biopsy for carcinoma-insitu, and screening at intervals of three to five years: I agree with both. Where I differ is on the issue of canvassing for healthy women to have the test, in the present state of our knowledge; but even here his proposition that " we should foster the gradual development of a service " is one to which I could assent. What should be avoided are the emotional overtones and the wholesale
on
hysterectomies. Dr. Parker’s letter is another matter. His statement that " 200 Sussex women to whom we offered a chance of life have died of cancer " has been reported in the local press, under the four-column headline " The 200 Doomed Cancer Victims " and subtitled " They might have lived if doctors had helped with the Parker Plan ". Boyes et al.,2 organising a large and well-planned campaign in British Columbia which has been going on for twelve years, found a drop in incidence of clinically invasive squamous carcinoma from 28-4 per 100,000 in 1955 to 19-7 per 100,000 in 1960. Dr. Parker’s figures are so wildly at variance with this result that I hope he will immediately justify them, or retract them. The false impression which they will otherwise make can do untold
been evolved which is shortly due to come into operation. I should add that diagnostic cervical cytology has been available for hospital patients in this area for the past seven
years.
It should be clear, therefore, that personal feelings have not been the cause of the delay of which Dr. Parker
complains. Royal Sussex County Hospital, Brighton.
R. W. P.
JOHNSON.
CONTROL OF FILARIAL WORMS
SIR,-Inote with interest the comments of Dr. Rabindran (June 15) on allergies provoked by diethylcarbamazine in patients with onchocerciasis. Whatever the mechanism involved, the effect on the patient is such that I have known many refuse diethylcarbamazine (’ Banocide ’) therapy. In my experience, the intense pruritus, dermatitis, oedema, and sometimes adenitis provoked by diethylcarbamazine is not often controlled by anti-histamines to any significant extent, and drugs such as promethazine may merely convert a patient from scratching while awake to scratching in his sleep. The heavily infested native patient seldom seems to benefit from diethylcarbamazine therapy alone, and he may be made to feel much worse. In the new case the drug may be curative, but between these two extremes lie a range of patients: usually the non-native temporary residents of an endemic routine " skin area, in whom the disease is revealed by a snip, or skin snips undertaken because of a trivial patch of dermatitis. These patients are then given a course of diethylcarbamazine, and suffer the attendant miseries of the sideeffects. Significantly, a year or so later, a further course of this drug is given, either because the patient is reinfested, or because he has relapsed, and is again suffering from pruritus. Having seen this cycle repeated many times, one is led to question the logic of such a regimen. More extended trials might be given as an adjunct to the " usual course"of diethylcarbamazine to long-term, intermittent, or continuous low-dosage suppressive therapy, using the drug in doses aimed at reducing the skin microfilaria population to insignificant "
values. Head Office, Cameroons Development Corporation, West Cameroon.
J. T. TRENCHAM.
BILLROTH AND CARDIAC SURGERY
apologise for not reacting earlier to two letters 1 2 concerning Billroth and cardiac surgery in which reference is made to our book, Pages in the History of Chest Surgery. SIR,-Ihave
to
There are two remarks of Billroth about cardiac surgery. The first is concerned with pericardial effusion and reads as translated by Mr. Richardson. This remark dates back R. I. K. ELLIOTT. Hove, Sussex. as far as because 1864, Rose,3 Billroth’s successor probably in the chair of of the of Zurich, published University surgery facets which Dr. SiR,—This problem has two distinct a paper on Herztamponade in 1884, in which he writes: " While there is the Parker has confused. On the one hand, in France and Russia many people were saved by personal opinion of individual pathologists as to the already of the pericardium, Billroth-hardly twenty years advisability of starting a scheme for an annual genital paracentesis himself as contemptuously as possible about this ago-expressed check for cancer on all women over 35. On the other operation, this certainly was the general opinion in Germany hand, there are the practical problems involved. at this time." On the one occasion when Dr. Parker approached the The second saying, that a surgeon attempting the suture of a heart should lose the esteem of his colleagues because this group pathologists to discuss his scheme it was pointed out to him that the National Health Service facilities were operation is not compatible with a surgeon’s responsibility, is placed in the year 1881. When Sauerbruch wrote the manunot adequate-if indeed they were entitled to be usedfor such a purpose. Since that time our cytologist has own script of the second volume (1925) of his work Thoracic he asked me to find out the exact source of this numerous occasions discussed with those interested in the Surgery remark. I was unable to find it in Billroth’s own writings scheme the practical possibilities of supplying the services and consequently approached van Eiselsberg, at that time needed in other wavs and a small oilot scheme has in fact
m;"1.rn;pf
1. 2.
Evening Argus, July 26. Boyes, D. A., Fidler, H. K., Lock,
D. R. Brit.
med. J. 1962, i,
203.
1. 2. 3.
Richardson, R. G. Lancet, 1963, i, 1216. Richardson, R. G. ibid. p. 1323. Rose, E. Dtsch. Z. Chir. 1884, 20, 329.
251
professor of surgery at Vienna University, who once wa: Billroth’s assistant. He replied that as far as he rememberec this remark was made by Billroth at a meeting of the Viennf Medical Society before he, von Eiselsberg, became Billroth’! Therefore ir 1881. Sauerbruch’s book 1881 was given as the year of this remark. I regret that Dr. Wilson and I have given a wrong reference by stating that Billroth’s remarks to cardiac surgery are founc in the 1893 edition of his Textbook on General Surgery. Chirurgische Universitätsklinik, RUDOLF NISSEN. Basle, Switzerland.
assistant, approximately in 1880
or
SURGICAL TREATMENT OF PEPTIC ULCERATION SiR,ŁYour leading article1 failed to mention an important point: the conservative operation of vagotomy and pyloroplasty can be recommended to a patient with a duodenal ulcer early in his illness. On the other hand, a gastrectomy, because of its sequelae, can be done only after the patient has suffered a long time-after he has " earned " his gastrectomy. In a recent paper2recommended a gastrectomy only for the " 10 % " of patients in whom the original vagotomy and pyloroplasty has failed. I fully agree with Mr. Burgethat the pyloroplasty must be as thoroughly and adequately done as the vagotomy. I believe, however, that the time needed to do the electrical stimulation test for escaped vagal fibres can be spent better by searching for these fibres. If both the vagotomy and the pyloroplasty are done thoroughly, a gastrectomy can be reserved for the occasional complicated duodenal ulcer. I also do not believe that acid studies should be used in choosing the type of operation for duodenal ulceration. B. J. V. R. DREYER. Cape Town.
investigated as sites of origin of reflex biliary dyskinesia cases presenting with symptoms of cholecystitis and a
in
negative cholecvstoeram. Cape
M. GLASS.
Town.
ACTIVE ALERTED POSTURE SIR In a recent article and in a television interview,i Dr. Joseph, the author of a book on posture,2 asks orthopaedic surgeons three questions: Are there any diseases which you say are due to defects ? Have you treated these cases by changing that
postural person’s
posture ? Has the disease been cured by changing the posture ? The answer, according to him, is No to all three, but according to a number of orthopaedic surgeons whom I have asked the answer is an emphatic Yes.
Dr.
Joseph will probably
agree that
a
person
standing
service at tennis, or to take the ball as a wicket-keeper, is in an alerted position in which all the muscles register some electrical reaction. This is what I have described as " active alerted posture ", in which the average person, with practice, can always learn to be prepared for action.3
ready
to run a race, to
accept
a
weight is carried on the outer side of the foot, the grip the ground, the knees are slightly bent, the abdominal
The toes
muscles are held up and in, the buttocks are held firm with the natal folds compressed, the shoulders are held up and slightly forwards, and the back of the neck is made as long as possible. The muscles are now in balanced contraction at the prime fixing levels. In fact, after long practice the balanced contraction of the muscles produces a perfectly relaxed person. Activating movements can take place at a moment’s notice without fear of putting strain on the muscles or the under-
lying joints. SYMPTOMS OF GALLBLADDER DISEASE WITH A NEGATIVE CHOLECYSTOGRAM
SIR,-The article by Mr. Cronin and Mr. Middleton4 prompts me to report the case of a 45-year-old married woman complaining of frequent, fairly long-continued episodes of nausea, epigastric fullness, stabbing pains under the right intercostal margin associated with a feeling of’tightness, and a dragging sensation in that area on
lying
on
her left side.
Apart from a slight tenderness in the region of her gallbladder, examination, including X-ray of her upper gastrointestinal tract and gallbladder, was negative. She was reassured, was advised to leave off coffee, which seemed to exacerbate her symptoms, and was given a course of ’Bellergal ’ and discharged. She returned six months later with her symptoms unchanged, having meanwhile had a cervical polyp removed and a course of cestogens given without relief. The physical findings were essentially unchanged; but on this occasion a superficial linear fissure about 3 mm. long with hyperasmic margins was noticed at just inside the entrance to the right auditory canal. Since dabbing with 70% alcohol evoked local stinging, the fissure was covered with a swab soaked in 10% cocaine hydrochloride. In five minutes all epigastric discomfort and nausea disappeared, and the patient could be on her left side in complete comfort. Cauterisation of the lesion was followed by complete relief for a year, after which a recurrence of her cholocystic symptoms was again scotched by attention to her right auditory canal-the lesion this time being on the isthmus.
Because I have seen 2 similar cases, I suggest that the territory of the auricular branch of the vagus should be 1. 2. 3.
Lancet, 1963, i, 1087. Dreyer, B. J. v. R. S. Afr. med. J. 1963, 37, 190. Lancet, 1963, i, 1211. 4. Cronin, K., Middleton, M. D. ibid. p. 1392.
Some may think this is an artificial posture, but with practice one can stand actively alerted for as long as eight hours a day, provided that in the other sixteen hours one sits or lies in a chair or bed with the joints held supported in a neutral position. This recumbent position I call " passive supported
posture ". Active alerted posture should be encouraged for low back a person bends forward in what Dr. Joseph describes as normal posture (and which I call " inactive slumping posture ") the weight of the trunk, head, and arms is the activating force. A bending strain is thrown on the lumbosacral joint at the level of the waist, and if in this position a weight is lifted suddenly there is every chance that one of the components of a spinal joint, such as a disc or an apophyseal joint, will be injured. In active alerted posture, when one bends forward there is no break at the lumbosacral level, because the trunk and the pelvis move together. Forward flexion takes place at the hip-joints, in the same way that anyone with a low back disc trouble is advised to pick up objects by bending at his hips and knees. When a jet plane lands its estimated speed is somewhere about 150 m.p.h. and air-brakes are used to keep the plane on the ground; these are propellers driven in reverse to check the forward thrust of the plane. Similarly, in active alerted posture the anterior and lateral abdominal muscles and the posterior spinal muscles are in balanced contraction, and the lumbosacral joint is fixed as in a vice. The result is that when the patient bends forward the trunk and pelvis move as one, and the abdominal muscles act as a brake in the same way as the reversed propellers in the aircraft. Posture has a part in the causation of symptoms of foot strain. There are two functions of the foot-static and dynamic. Sir Arthur Keith and Professor Wood Jones
pain. When
1. 2.
Joseph, J. Family Doctor, 1963, 13, 92. Joseph, J. Man’s Posture: Electromyographic Studies. Springfield, Ill., 1960. 3. Tucker, W. E. Active Alerted Posture. Edinburgh and London, 1960.