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BLOOD AND BONES
908 Next comes the certificate " for a few days, to get over it ". On discharge from the hospital he misses the supervision, symptoms develop, days turn into weeks, and examinations on behalf of the National Insurance, insurance companies, trade union, employers, and often others produce a man who is a misery, a burden, and a bore to himself, his family, and his friends. Fortunate is the man who is seen by his own doctor or the works doctor, carefully examined, and told that he should be perfectly all right after half an hour’s lie-down, and only to call medical aid if he feels unwell.
On the other side of the picture are the tragic cases of unsuspected intracranial complications in the apparently trivially injured. Mr. Potter suggests that anyone in doubt on the question of admissions should read James and Turner. Being in some doubt I did so. The first impression I obtained was of examples of serious complications in patients who had not suffered unconsciousness or amnesia at all. Should we perhaps observe all blows to the head for 48 hours or longer in hospital ? Before we expend more time on chasing an elusive minority, let us be sure that the treatment of the majority is satisfactory. Let us eavesdrop on a telephone conversation in an imaginary busy provincial hospital: Nurse: The head injury case, Mr. Jones in bed 9, has been in for 24 hours, and we need his bed for an emergency. Can we discharge him ? H.S. (or registrar): Is he all right ? Nurse: Oh yes, quite well. Doctor: O.K., let him go. now
The patient, who has been carefully watched for 24 hours or more, finds himself on the way home without a final examination or reassurance. He is going to need " a lot of aftercare ". D. H. EATON. Mansfield.
SIR,-Your
BLOOD AND BONES leading article (Oct. 3) gives
a
lucid account
arthroplasty or
post mortem, to determine the incidence of ischaemic necrosis, and the mode of revascularisation of the
capital fragment. These studies should provide much-needed information the factors responsible for the high failure-rate in fractures of the neck of the femur, and indicate if this can be lowered by improved methods of osteosynthesis. It should also clarify the indications for a primary prosthetic on
replacement. University Department of Orthopædic Surgery, Western Infirmary, Glagow, W.1.
COMBINED THERAPY IN MALIGNANT DISEASE SIR,-Your sensible editorial (Oct. 10) may be a little misleading in regard to treatment of retinoblastoma. You quote me as reporting 72% ten-year survival in 79 cases "treated by radiotherapy alone ".1 This is incorrect. This figure referred to 79 unselected cases-all those seen in the Manchester region between 1901 and 1947 who could be followed up by Steward.2
patients were treated primarily by surgery, though 21 also given radiotherapy, and 2 were untreated (adult cases with spontaneous regression many years before being seen as relatives of other cases). The 72% ten-year survival in these unselected cases was contrasted with the three-yearsurvival rate of 73% (only 1 patient dying between three and ten years after diagnosis). Further details were reported of 38 patients treated by means of radiotherapy. These figures cannot be compared with the survival-rate of the specially selected group of patients in whom one eye has already been removed, and in whom there is tumour in the second eye of limited extent suitable for radiotherapy with hope of preservation of useful sight. Results of treatment in this group should be assessed in terms of survival-rate with useful vision. Combined chemotherapy (if harmless to the eye) and radiotherapy might possibly be of special value in these cases, since radiation dosage may be limited because of possible damage to the eye. Christie Hospital and The
were
Holt Radium Institute,
Withington, Manchester, 20.
of the unsolved problems of femoral neck fractures, and our inadequate knowledge of the factors responsible for the high rate of non-union. Catto3 in this hospital has studied histologically 47 femoral heads removed post mortem or at a replacement arthroplasty; in two-thirds of these there was total or partial necrosis. This figure agrees with the observations of Boyd and Calandruccio4 and Woodhouse.5 Although the incidence of ischsemic necrosis is lower than the figure of 84% found by Sevitt,6 it does support your contention that an important number of ischaemic heads are capable of healing. Nicollin an editorial article to which you refer, made a plea for a prospective survey of a minimum of 500 transcervical fractures, and you express the hope that collaboration between groups of surgeons can make this feasible. You will be pleased to know that the Medical Research Council has agreed to sponsor a prospective survey of a minimum of 1000 transcervical fractures. Surgeons from 18 orthopxdic centres in the United Kingdom have agreed to collaborate in the survey under the chairmanship of Mr. Nicoll, and it is hoped to achieve a high rate of follow-up over a period of three years. A small assessment panel will meet regularly, and they will be responsible for an objective analysis of radiographs taken at regular intervals; the observations will be subjected to rigorous statistical analysis. Parallel studies are being made into the incidence of osteoporosis in patients who sustain transcervical fractures, and its effect on union, and a histological examination will be made of femoral heads removed at a replacement 2. 3. 4. 5. 6. 7.
James, T. G. I., Turner, E. A. Lancet, 1951, ii, 45. Catto, M.E. unpublished. Boyd, H. B., Calandruccio, R. A. J. Bone Jt Surg. 1963, 45A, 445. Woodhouse, C. S. ibid. 1962, 44A, 1029. Sevitt, S. ibid. 1964, 46B, 270. Nicoll, E. A. ibid. 1963, 45B, 239.
ROLAND BARNES.
KEITH E. HALNAN.
CANCER RISK IN ULCERATIVE COLITIS
SIR,-Ishould like to comment on some points in Mr. Aylett’s letter (Oct. 10). First, I agree absolutely about the importance of removing rectum when it is badly strictured. Mr. Aylett does well emphasise the high cancer risk in these patients. This is a point which perhaps I ought to have brought out in my paper, and I am glad that Mr. Aylett has rectified this omission. With reference to the incidence of malignant disease in the rectal remnant in his personal series, it is difficult to compare his figure of 3 in 285 operated cases with those reported by me, because data concerning length of follow-up and age-distribution and sex-distribution are needed before this figure can be
the to
used to estimate cancer risk. So far as the effect of extent of colitis on cancer incidence is concerned, I have no evidence as to the cause of the differences observed; one could perhaps speculate that total-colitis patients are for the most part those with the most severe disease and that this renders them especially liable to a higher incidence of all the complications of ulcerative colitis. The difference in the cancer incidence in relation to extent of disease in the bowel is commented upon by Edwards and Truelove3 and Nefzger and Acheson.4 I have seen very many of Mr. Aylett’s patients after
their operations and have been tremendously impressed by their wellbeing and by the excellence of the functional result in his hands. I am quite sure that the maiority of 1. 2. 3. 4.
Halnan, K. E. Clin. Radiol. 1962, 13, 19. Steward, J. K. M.D. thesis, University of Manchester, 1959. Edwards, F. C., Truelove, S. C. Gut, 1964, 5, 15. Nefzger, M. D., Acheson, E. D. ibid. 1963, 4, 103.
,
On the other side of the picture are the tragic cases of unsuspected intracranial complications in the apparently trivially injured. Mr. Potter suggests that anyone in doubt on the question of admissions should read James and Turner. Being in some doubt I did so. The first impression I obtained was of examples of serious complications in patients who had not suffered unconsciousness or amnesia at all. Should we perhaps observe all blows to the head for 48 hours or longer in hospital ? Before we expend more time on chasing an elusive minority, let us be sure that the treatment of the majority is satisfactory. Let us eavesdrop on a telephone conversation in an imaginary busy provincial hospital: Nurse: The head injury case, Mr. Jones in bed 9, has been in for 24 hours, and we need his bed for an emergency. Can we discharge him ? H.S. (or registrar): Is he all right ? Nurse: Oh yes, quite well. Doctor: O.K., let him go. now
The patient, who has been carefully watched for 24 hours or more, finds himself on the way home without a final examination or reassurance. He is going to need " a lot of aftercare ". D. H. EATON. Mansfield.
SIR,-Your
BLOOD AND BONES leading article (Oct. 3) gives
a
lucid account
arthroplasty or
post mortem, to determine the incidence of ischaemic necrosis, and the mode of revascularisation of the
capital fragment. These studies should provide much-needed information the factors responsible for the high failure-rate in fractures of the neck of the femur, and indicate if this can be lowered by improved methods of osteosynthesis. It should also clarify the indications for a primary prosthetic on
replacement. University Department of Orthopædic Surgery, Western Infirmary, Glagow, W.1.
COMBINED THERAPY IN MALIGNANT DISEASE SIR,-Your sensible editorial (Oct. 10) may be a little misleading in regard to treatment of retinoblastoma. You quote me as reporting 72% ten-year survival in 79 cases "treated by radiotherapy alone ".1 This is incorrect. This figure referred to 79 unselected cases-all those seen in the Manchester region between 1901 and 1947 who could be followed up by Steward.2
patients were treated primarily by surgery, though 21 also given radiotherapy, and 2 were untreated (adult cases with spontaneous regression many years before being seen as relatives of other cases). The 72% ten-year survival in these unselected cases was contrasted with the three-yearsurvival rate of 73% (only 1 patient dying between three and ten years after diagnosis). Further details were reported of 38 patients treated by means of radiotherapy. These figures cannot be compared with the survival-rate of the specially selected group of patients in whom one eye has already been removed, and in whom there is tumour in the second eye of limited extent suitable for radiotherapy with hope of preservation of useful sight. Results of treatment in this group should be assessed in terms of survival-rate with useful vision. Combined chemotherapy (if harmless to the eye) and radiotherapy might possibly be of special value in these cases, since radiation dosage may be limited because of possible damage to the eye. Christie Hospital and The
were
Holt Radium Institute,
Withington, Manchester, 20.
of the unsolved problems of femoral neck fractures, and our inadequate knowledge of the factors responsible for the high rate of non-union. Catto3 in this hospital has studied histologically 47 femoral heads removed post mortem or at a replacement arthroplasty; in two-thirds of these there was total or partial necrosis. This figure agrees with the observations of Boyd and Calandruccio4 and Woodhouse.5 Although the incidence of ischsemic necrosis is lower than the figure of 84% found by Sevitt,6 it does support your contention that an important number of ischaemic heads are capable of healing. Nicollin an editorial article to which you refer, made a plea for a prospective survey of a minimum of 500 transcervical fractures, and you express the hope that collaboration between groups of surgeons can make this feasible. You will be pleased to know that the Medical Research Council has agreed to sponsor a prospective survey of a minimum of 1000 transcervical fractures. Surgeons from 18 orthopxdic centres in the United Kingdom have agreed to collaborate in the survey under the chairmanship of Mr. Nicoll, and it is hoped to achieve a high rate of follow-up over a period of three years. A small assessment panel will meet regularly, and they will be responsible for an objective analysis of radiographs taken at regular intervals; the observations will be subjected to rigorous statistical analysis. Parallel studies are being made into the incidence of osteoporosis in patients who sustain transcervical fractures, and its effect on union, and a histological examination will be made of femoral heads removed at a replacement 2. 3. 4. 5. 6. 7.
James, T. G. I., Turner, E. A. Lancet, 1951, ii, 45. Catto, M.E. unpublished. Boyd, H. B., Calandruccio, R. A. J. Bone Jt Surg. 1963, 45A, 445. Woodhouse, C. S. ibid. 1962, 44A, 1029. Sevitt, S. ibid. 1964, 46B, 270. Nicoll, E. A. ibid. 1963, 45B, 239.
ROLAND BARNES.
KEITH E. HALNAN.
CANCER RISK IN ULCERATIVE COLITIS
SIR,-Ishould like to comment on some points in Mr. Aylett’s letter (Oct. 10). First, I agree absolutely about the importance of removing rectum when it is badly strictured. Mr. Aylett does well emphasise the high cancer risk in these patients. This is a point which perhaps I ought to have brought out in my paper, and I am glad that Mr. Aylett has rectified this omission. With reference to the incidence of malignant disease in the rectal remnant in his personal series, it is difficult to compare his figure of 3 in 285 operated cases with those reported by me, because data concerning length of follow-up and age-distribution and sex-distribution are needed before this figure can be
the to
used to estimate cancer risk. So far as the effect of extent of colitis on cancer incidence is concerned, I have no evidence as to the cause of the differences observed; one could perhaps speculate that total-colitis patients are for the most part those with the most severe disease and that this renders them especially liable to a higher incidence of all the complications of ulcerative colitis. The difference in the cancer incidence in relation to extent of disease in the bowel is commented upon by Edwards and Truelove3 and Nefzger and Acheson.4 I have seen very many of Mr. Aylett’s patients after
their operations and have been tremendously impressed by their wellbeing and by the excellence of the functional result in his hands. I am quite sure that the maiority of 1. 2. 3. 4.
Halnan, K. E. Clin. Radiol. 1962, 13, 19. Steward, J. K. M.D. thesis, University of Manchester, 1959. Edwards, F. C., Truelove, S. C. Gut, 1964, 5, 15. Nefzger, M. D., Acheson, E. D. ibid. 1963, 4, 103.
,