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PEPTIC ULCERATION
1101
splenectomy Ithetithsplenectomy.
is due to the
ligation
rather than to
These considerations have led me to discard the operation of ligation of the hepatic artery and I continue to advocate splenectomy followed by portacaval anastoJ]1osis for any patient with cirrhosis, splenomegaly, and varices. FRANCIS E. STOCK University University of Hong-Kong.
tI BMphageal
Professor of Surgery.
CONTRACEPTIVE
TECHNIQUE
SiB,—The
letter from the managing director of Ortho pharmaceutical Ltd. should not satisfy anyone in charge of a birth-control clinic, and does not satisfy me, though it advertises further the contraceptives I " am warning and jelly Mr. George people about. The diaphragm entirely satisfactory praises I have long shown to be a not . technique.1 Though theoretically it would be very nice to have a suppository or substance that would do away with the necessity for any diaphragm cap or barrier, there are reasons which make this unlikely of achievement. Mr. George claims that their advertised product -Preceptin Vaginal Gel’-is safe without any barrier. First let me say it has to be placed with an applicator, and for general contraceptive use I condemn all methods the use of an applicator, which has many bad "
involving jehy-like
features. Further, a method involving the use only of a substance ignores the fact that in coitus the iperm may be ejaculated directly into the uterus, when none of the substance’s alleged unique capacity to destroy sperms would be able to take effect.2 The Ortho Research Foundation speaks of thousands of patients." What degree of safety after at least one year’s, and preferably two years’, consistent use of this as the only contraceptive do they claim ? We should be given also one or two addresses of recommended clinics in this country where this contraceptive has been consistently used, and the degree of success they record. "
C.B.C. Birth Control Clinic, 108, Whitfield Street, London, W.1.
’
MARIE C. STOPES President and Founder.
THE BRACHIAL-PALSY HAZARD SiR,—Though the Law may have to concern itself with a particular injury or an isolated event, doctors must try to regard the whole patient and his whole welfare. Recent interest in brachial-plexus injury subsequent to certain operating-table positions seems to illustrate this matter. Let us, for argument’s sake, admit that there is
a risk of brachial-plexus injury following maintained abduction of the arm under anesthesia. I believe that there are instances when the risk should forthrightly be accepted in the patient’s interest. Sometimes the continuance of an intravenous infusion is of critical importance to the patient because of collapse. Sometimes sudden and unpredicted interruption of the flow of the infusion might disrupt the smooth course of Mssthesia given by the method judged best for the patient’s survival, and such sudden disruption at a critical point in the operation could have grave consequences. In patients in a shocked state veins in the leg are often unsatisfactory, and an infusion into a forearm vein can easily fail unless the arm is accessible so that attention can be given immediately when needed. tnless the arm is abducted such attention is either impossible or imperfect. If the arm be only a little abducted the surgeon may be hampered by it and the patient’s interests thereby damaged. Even though it may expose me to the risk of being deemed negligent, I shall continue as occasion requires to place an infusion in a forearm vein, and abduct the arm onto an arm-board so that I can be as sure as 1. Stopes, M. C. Med. World, Lond. Nov. 23, 1951. 2. Stopes, M. C. Clin. Med. Surg. March, 1931.
humanly possible that the flow continues. I shall do this because I believe that the conscientious application of knowledge and judgment to the patient’s whole welfare will not infrequently demand it ; though I shall be fully aware of the small risk to his brachial plexus. Department of Anæsthesia, Royal Victoria Infirmary,
E. A. PASK.
Newcastle upon Tyne.
** * Dr. Pask can, we believe, pursue his course safely for the patient if he makes one small concession to the brachial plexus : by using the Jackman arm-rest1 he can prevent the abducted arm from falling below the coronal plane of the body. At the same time, we should point out that many other devices for protecting the brachial plexus are already in successful use.2-ED. L. INTESTINAL
OBSTRUCTION
IN
INFANTS
SiR,—It was never the intention in my letter of April 4 to decry in any way the invaluable part played by special centres in the advancement of neonatal surgery, and I question whether such an interpretation is justified. Psediatric surgical centres’ in Boston, Liverpool, and Stockholm, among others, have in a few years turned a mortality-rate of 75% in intestinal obstruction of the newborn (excluding meconium ileus) into a survival-rate of 75% or better-truly a remarkable achievement. Progress in medicine and surgery characteristically follows a pattern by which one or more main centres develop new methods of treatment or new surgical techniques, which - are later successfully adopted by others. Surely this process can be profitably applied to abdominal surgery in the newborn, where early diagnosis and treatment are essential. W. P. SWEETNAM. Halifax General Hospital. PEPTIC ULCERATION
interested in Dr. Csato’s account (May 16) of treatment of peptic ulceration with injections of chorionic gonadotropin. Some time ago I was struck by a statement by a patient with duodenal ulcer that her symptoms always remitted when she was pregnant. As she had failed to respond to the usual medical remedies, I gave her a course of ethinylcestradiol sublingually (to avoid the irritant effect of the drug on the gastric mucosa). There was an immediate resolution of symptoms in 2-3 days ; but when she suffered a further exacerbation some 6 months later, there was complete failure to reproduce the same Neither did she respond to ethisterone given in like manner. Since then I have tried both hormones in 5 other cases, and methyltestosterone in 3 male patients. Symptoms have been completely relieved by ethisterone in 1 case, and by ethinylcestradiol in another ; but in the remaining 6 cases there was no effect. In 1 case methyltestosterone greatly aggravated the pain. In view of Dr. Csato’s observations, I intend to treat some further cases with injections of progesterone, as opposed to the less reliable oral preparation. There is, perhaps, a slight tendency to take for granted the natural history of diseases, without inquiring more deeply into possible causes for spontaneous remissions and variations. Thus pregnancy has often been classed as one of many intercurrent conditions which may cause remission in such diverse diseases as peptic ulceration, disseminated sclerosis, and rheumatoid arthritis. Yet this observation on rheumatoid arthritis was one of the factors leading directly to the discovery of cortisone. DAVID WHEATLEY. Twickenham, Middlesex.
SIR,-I
1.
was
Wilson, E. F., Murphy, T. T. P., Angel, R. E. Lancet, 1951, i, 511. Ibid, 1950, i, 99; Kiloh, L., pp. 103, 121; Galley, A. H., Gray, A. J., p. 184; Finnie, W. J., p. 228; Lunn, M., Clutton-Brock, J., Clarke, S. H. C., Gusterson, E. R., p. 229; Lee, M., p. 277; Browne, J. C. M., Roberts, H., p. 278; FitzGerald. T. B., p. 326; Ward, R. O., Rollason, W. N., p. 423; Sinclair, A. D., p. 592.
2. Ewing, M. R.
splenectomy Ithetithsplenectomy.
is due to the
ligation
rather than to
These considerations have led me to discard the operation of ligation of the hepatic artery and I continue to advocate splenectomy followed by portacaval anastoJ]1osis for any patient with cirrhosis, splenomegaly, and varices. FRANCIS E. STOCK University University of Hong-Kong.
tI BMphageal
Professor of Surgery.
CONTRACEPTIVE
TECHNIQUE
SiB,—The
letter from the managing director of Ortho pharmaceutical Ltd. should not satisfy anyone in charge of a birth-control clinic, and does not satisfy me, though it advertises further the contraceptives I " am warning and jelly Mr. George people about. The diaphragm entirely satisfactory praises I have long shown to be a not . technique.1 Though theoretically it would be very nice to have a suppository or substance that would do away with the necessity for any diaphragm cap or barrier, there are reasons which make this unlikely of achievement. Mr. George claims that their advertised product -Preceptin Vaginal Gel’-is safe without any barrier. First let me say it has to be placed with an applicator, and for general contraceptive use I condemn all methods the use of an applicator, which has many bad "
involving jehy-like
features. Further, a method involving the use only of a substance ignores the fact that in coitus the iperm may be ejaculated directly into the uterus, when none of the substance’s alleged unique capacity to destroy sperms would be able to take effect.2 The Ortho Research Foundation speaks of thousands of patients." What degree of safety after at least one year’s, and preferably two years’, consistent use of this as the only contraceptive do they claim ? We should be given also one or two addresses of recommended clinics in this country where this contraceptive has been consistently used, and the degree of success they record. "
C.B.C. Birth Control Clinic, 108, Whitfield Street, London, W.1.
’
MARIE C. STOPES President and Founder.
THE BRACHIAL-PALSY HAZARD SiR,—Though the Law may have to concern itself with a particular injury or an isolated event, doctors must try to regard the whole patient and his whole welfare. Recent interest in brachial-plexus injury subsequent to certain operating-table positions seems to illustrate this matter. Let us, for argument’s sake, admit that there is
a risk of brachial-plexus injury following maintained abduction of the arm under anesthesia. I believe that there are instances when the risk should forthrightly be accepted in the patient’s interest. Sometimes the continuance of an intravenous infusion is of critical importance to the patient because of collapse. Sometimes sudden and unpredicted interruption of the flow of the infusion might disrupt the smooth course of Mssthesia given by the method judged best for the patient’s survival, and such sudden disruption at a critical point in the operation could have grave consequences. In patients in a shocked state veins in the leg are often unsatisfactory, and an infusion into a forearm vein can easily fail unless the arm is accessible so that attention can be given immediately when needed. tnless the arm is abducted such attention is either impossible or imperfect. If the arm be only a little abducted the surgeon may be hampered by it and the patient’s interests thereby damaged. Even though it may expose me to the risk of being deemed negligent, I shall continue as occasion requires to place an infusion in a forearm vein, and abduct the arm onto an arm-board so that I can be as sure as 1. Stopes, M. C. Med. World, Lond. Nov. 23, 1951. 2. Stopes, M. C. Clin. Med. Surg. March, 1931.
humanly possible that the flow continues. I shall do this because I believe that the conscientious application of knowledge and judgment to the patient’s whole welfare will not infrequently demand it ; though I shall be fully aware of the small risk to his brachial plexus. Department of Anæsthesia, Royal Victoria Infirmary,
E. A. PASK.
Newcastle upon Tyne.
** * Dr. Pask can, we believe, pursue his course safely for the patient if he makes one small concession to the brachial plexus : by using the Jackman arm-rest1 he can prevent the abducted arm from falling below the coronal plane of the body. At the same time, we should point out that many other devices for protecting the brachial plexus are already in successful use.2-ED. L. INTESTINAL
OBSTRUCTION
IN
INFANTS
SiR,—It was never the intention in my letter of April 4 to decry in any way the invaluable part played by special centres in the advancement of neonatal surgery, and I question whether such an interpretation is justified. Psediatric surgical centres’ in Boston, Liverpool, and Stockholm, among others, have in a few years turned a mortality-rate of 75% in intestinal obstruction of the newborn (excluding meconium ileus) into a survival-rate of 75% or better-truly a remarkable achievement. Progress in medicine and surgery characteristically follows a pattern by which one or more main centres develop new methods of treatment or new surgical techniques, which - are later successfully adopted by others. Surely this process can be profitably applied to abdominal surgery in the newborn, where early diagnosis and treatment are essential. W. P. SWEETNAM. Halifax General Hospital. PEPTIC ULCERATION
interested in Dr. Csato’s account (May 16) of treatment of peptic ulceration with injections of chorionic gonadotropin. Some time ago I was struck by a statement by a patient with duodenal ulcer that her symptoms always remitted when she was pregnant. As she had failed to respond to the usual medical remedies, I gave her a course of ethinylcestradiol sublingually (to avoid the irritant effect of the drug on the gastric mucosa). There was an immediate resolution of symptoms in 2-3 days ; but when she suffered a further exacerbation some 6 months later, there was complete failure to reproduce the same Neither did she respond to ethisterone given in like manner. Since then I have tried both hormones in 5 other cases, and methyltestosterone in 3 male patients. Symptoms have been completely relieved by ethisterone in 1 case, and by ethinylcestradiol in another ; but in the remaining 6 cases there was no effect. In 1 case methyltestosterone greatly aggravated the pain. In view of Dr. Csato’s observations, I intend to treat some further cases with injections of progesterone, as opposed to the less reliable oral preparation. There is, perhaps, a slight tendency to take for granted the natural history of diseases, without inquiring more deeply into possible causes for spontaneous remissions and variations. Thus pregnancy has often been classed as one of many intercurrent conditions which may cause remission in such diverse diseases as peptic ulceration, disseminated sclerosis, and rheumatoid arthritis. Yet this observation on rheumatoid arthritis was one of the factors leading directly to the discovery of cortisone. DAVID WHEATLEY. Twickenham, Middlesex.
SIR,-I
1.
was
Wilson, E. F., Murphy, T. T. P., Angel, R. E. Lancet, 1951, i, 511. Ibid, 1950, i, 99; Kiloh, L., pp. 103, 121; Galley, A. H., Gray, A. J., p. 184; Finnie, W. J., p. 228; Lunn, M., Clutton-Brock, J., Clarke, S. H. C., Gusterson, E. R., p. 229; Lee, M., p. 277; Browne, J. C. M., Roberts, H., p. 278; FitzGerald. T. B., p. 326; Ward, R. O., Rollason, W. N., p. 423; Sinclair, A. D., p. 592.
2. Ewing, M. R.