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SURGICAL TREATMENT OF PEPTIC ULCERATION
361 mechanism by which these compounds produce the decrease of anticoagulant tolerance is so far unknown. C17-alkylated steroids are known to cause abnormalities of some liver-function tests-abnormal bromsulphalein retention and increased serum-transaminase levels.4"’ Evidently the effect of C17alkylated steroids on anticoagulant tolerance is in some way linked with other effects of these drugs on the liver. The effect of C17-alkylated testosterone derivatives on lipid metabolism has become a subject of keen interest, because these compounds have been found to reduce serum cholesterol and triglyceride levels.2 s-10 According to Dr. Furman and his associates,2 increased sensitivity to anticoagulant drugs develops in hyperglyceridxmic subjects, irrespective of the means used to achieve the decrease of serum-lipids. Unfortunately, we did not determine serum-lipid levels in our patients systematically and cannot comment on this point. Professor Nikkila and Dr. Pelkonen 11 suggest that abnormalities of vitamin-K metabolism may explain the great requirements of anticoagulant
drugs in hyperlipidsemic subjects. If the decrease of anticoagulant tolerance during administration of C17-alkylated steroids can be shown to be related to the effect of these compounds on lipid metabolism, alteration of vitamin-K metabolism must be regarded
as a
nossible
cause.
KALEVI PYÖRÄLÄ MATTI KEKKI.
Department of Medicine III, University of Helsinki, Finland.
TONSILLECTOMY
SIR,-In your annotation of July 20 the omission of group 1 (cases requiring urgent tonsillectomy) from the discussion is regretted, presumably because some odd people do not agree that tonsillectomy is ever urgent or beneficial. Such people merely close their minds to facts, or they are unaware of the facts, in which event it would be better not to air their views. If a child is severely obstructed, what does one do ? Air an opinion, insert an airway, or do something useful ? Now I regard myself as fairly conservative, but the one category about which there
can
be
no
doubt is
group
1.
F. MCGUCKIN. EMPIRICISM
SIR,-Plato, Hippocrates, and Aristotle distinguished regarding applied sciences and particularly Medicine Techne and Empiria. Techne was for them the real, rational scientific method and consisted in approaching the patient for diagnosis and treatment and in general in studying medical problems on the basis of previous clinical observations combined with consideration of the deep nature of disease and of the mechanism of action of therapeutical agents-thus of physiopathological thinking. Empiria is not a scientific method. It consists in approaching the medical problems nearly exclusively on the basis of previous observation and experiment without any attempt at deeper interpretation. It leads to errors because it banishes reflection and runs the danger of taking as similars things that are not similar. It bars scientific progress as it does not allow the " break-through " needed in creative scientific work. Techne-that is, the rational scientific method-demands a perfect balance between observed facts and interpretative physiopathological conceptions. A rupture of this balance, an approach to medical problems predominantly based on physiopathological conceptions, leads to dogmatism and thus to a chaos of speculations, whereas such an approach based only on Wernze, H. Dtsch. med. Wschr. 1960, 85, 2237. Marquardt, G. H., Fisher, C. I., Levy, P., Dowben, R. M. J. Amer. med. Ass. 1961, 175, 115. 6. Werner, M., Hitz, A., Gloor, F., Thölen, H. Klin. Wschr. 1961, 39, 1006. 7. Wynn, V., Landon, J., Kawerau, E. Lancet, 1961, i, 69. 8. Howard, R. P., Furman, R. H. J. clin. Endocrin. 1962, 22, 43. 9. Mosbach, E. H., Blum, J. Circulation, 1962, 26, 663. 10. Stone, M. C. Lancet, 1963, i, 477. 11. Nikkilä, E. A., Pelkonen, R. ibid. p. 332. 4. 5.
previous observations and experiments leads to empiricism and thus to sterility. Empiricism can be applied to computers and electronic brains, Techne demanding creative thinking is an apanage of the human intellect. It is erroneous to translate the Techne of the Greeks, which is synonymous with rational scientific thinking, as " Art ". The first aphorism of Hippocrates should not read " Life is short, Art is long " but (as in the translation of Chadwick and Mann)1 " Life is short, Science is long ". University Faculty of Medicine, CAWADIAS. Athens.
A. P.
SURGICAL TREATMENT OF PEPTIC ULCERATION SIR,-Mr. Dreyer (Aug. 3) agrees that when vagotomy is used the pyloroplasty must be " thoroughly and adequately done "; for antral retention is one of the two causes of recurrent ulceration. He does not use the electrical stimulation test for completeness of nerve section, but prefers to spend the time needed for the test in searching for nerve-fibres. One in ten of his patients come to gastrectomy because of failure of the vagotomy. In the hands of a surgeon experienced in vagotomy, small nerve-trunks are left undivided in about 30% of patients despite the most careful search. Because he can neither see nor feel these small trunks, the surgeon believes he has achieved complete nerve section; only the electrical stimulation test to light his error. Of 200 in whom the test has been used over a five-year period, 1 had to be operated on again, and was proved by the test at the second operation to have two small retained nervetrunks. The original test failed in his case because of technical difficulties in its early days. There is 1 other case of recurrent ulceration due to antral retention between a stenosed duodenum and the gastroenterostomy stoma. Both recurrences were due to avoidable error. From this, recurrent ulceration seems always to be caused by a persistent cephalic phase of acid secretion, by incomplete nerve section, or by an augmented hormonal phase from antral retention. In the physiological laboratory it has been shown that small intact nerve-trunks may produce a high acid secretion, and in clinical practice they have been shown to cause recurrent ulceration.
brings
It does seem that vagotomy in this country is falling somewhat into disfavour for a second time, and again because of incomplete nerve section. It is a pity that this should be so when the means exist to prevent it. West London
Hospital, Hammersmith, W.6.
HAROLD BURGE.
HYPOTENSIVE ANÆSTHESIA are of great importance in increasing our understanding of physiological flow processes. It is therefore absolutely essential that observations on models are interpreted correctly and that great care is taken in extrapolating model results to live
SiR,ŁFlow experiments in models
conditions. We are prompted to make these comments by the observation of Dr. Osborn (July 20) that reducing the flow in a model of the left coronary artery converted laminar (streamline) flow to turbulence. This is contrary to experimental observations and theoretical predictions made over the past sixty years and consequently calls for some
scepticism.
We observe from the illustration of the model (fig. 2 in Dr. Osborn’s letter) that small particles were used as a tracer in the flow experiments. As a means of detecting turbulence this is rather dangerous. If the particles are slightly denser than the surrounding fluid, then at high speeds they will not follow the turbulent movement of the fluid but, owing to their greater inertia, will move uniformly in the general direction of the flow. 1. Chadwick, J., Mann, W. N. The Medical Works of Hippocrates. Oxford, 1950.
drugs in hyperlipidsemic subjects. If the decrease of anticoagulant tolerance during administration of C17-alkylated steroids can be shown to be related to the effect of these compounds on lipid metabolism, alteration of vitamin-K metabolism must be regarded
as a
nossible
cause.
KALEVI PYÖRÄLÄ MATTI KEKKI.
Department of Medicine III, University of Helsinki, Finland.
TONSILLECTOMY
SIR,-In your annotation of July 20 the omission of group 1 (cases requiring urgent tonsillectomy) from the discussion is regretted, presumably because some odd people do not agree that tonsillectomy is ever urgent or beneficial. Such people merely close their minds to facts, or they are unaware of the facts, in which event it would be better not to air their views. If a child is severely obstructed, what does one do ? Air an opinion, insert an airway, or do something useful ? Now I regard myself as fairly conservative, but the one category about which there
can
be
no
doubt is
group
1.
F. MCGUCKIN. EMPIRICISM
SIR,-Plato, Hippocrates, and Aristotle distinguished regarding applied sciences and particularly Medicine Techne and Empiria. Techne was for them the real, rational scientific method and consisted in approaching the patient for diagnosis and treatment and in general in studying medical problems on the basis of previous clinical observations combined with consideration of the deep nature of disease and of the mechanism of action of therapeutical agents-thus of physiopathological thinking. Empiria is not a scientific method. It consists in approaching the medical problems nearly exclusively on the basis of previous observation and experiment without any attempt at deeper interpretation. It leads to errors because it banishes reflection and runs the danger of taking as similars things that are not similar. It bars scientific progress as it does not allow the " break-through " needed in creative scientific work. Techne-that is, the rational scientific method-demands a perfect balance between observed facts and interpretative physiopathological conceptions. A rupture of this balance, an approach to medical problems predominantly based on physiopathological conceptions, leads to dogmatism and thus to a chaos of speculations, whereas such an approach based only on Wernze, H. Dtsch. med. Wschr. 1960, 85, 2237. Marquardt, G. H., Fisher, C. I., Levy, P., Dowben, R. M. J. Amer. med. Ass. 1961, 175, 115. 6. Werner, M., Hitz, A., Gloor, F., Thölen, H. Klin. Wschr. 1961, 39, 1006. 7. Wynn, V., Landon, J., Kawerau, E. Lancet, 1961, i, 69. 8. Howard, R. P., Furman, R. H. J. clin. Endocrin. 1962, 22, 43. 9. Mosbach, E. H., Blum, J. Circulation, 1962, 26, 663. 10. Stone, M. C. Lancet, 1963, i, 477. 11. Nikkilä, E. A., Pelkonen, R. ibid. p. 332. 4. 5.
previous observations and experiments leads to empiricism and thus to sterility. Empiricism can be applied to computers and electronic brains, Techne demanding creative thinking is an apanage of the human intellect. It is erroneous to translate the Techne of the Greeks, which is synonymous with rational scientific thinking, as " Art ". The first aphorism of Hippocrates should not read " Life is short, Art is long " but (as in the translation of Chadwick and Mann)1 " Life is short, Science is long ". University Faculty of Medicine, CAWADIAS. Athens.
A. P.
SURGICAL TREATMENT OF PEPTIC ULCERATION SIR,-Mr. Dreyer (Aug. 3) agrees that when vagotomy is used the pyloroplasty must be " thoroughly and adequately done "; for antral retention is one of the two causes of recurrent ulceration. He does not use the electrical stimulation test for completeness of nerve section, but prefers to spend the time needed for the test in searching for nerve-fibres. One in ten of his patients come to gastrectomy because of failure of the vagotomy. In the hands of a surgeon experienced in vagotomy, small nerve-trunks are left undivided in about 30% of patients despite the most careful search. Because he can neither see nor feel these small trunks, the surgeon believes he has achieved complete nerve section; only the electrical stimulation test to light his error. Of 200 in whom the test has been used over a five-year period, 1 had to be operated on again, and was proved by the test at the second operation to have two small retained nervetrunks. The original test failed in his case because of technical difficulties in its early days. There is 1 other case of recurrent ulceration due to antral retention between a stenosed duodenum and the gastroenterostomy stoma. Both recurrences were due to avoidable error. From this, recurrent ulceration seems always to be caused by a persistent cephalic phase of acid secretion, by incomplete nerve section, or by an augmented hormonal phase from antral retention. In the physiological laboratory it has been shown that small intact nerve-trunks may produce a high acid secretion, and in clinical practice they have been shown to cause recurrent ulceration.
brings
It does seem that vagotomy in this country is falling somewhat into disfavour for a second time, and again because of incomplete nerve section. It is a pity that this should be so when the means exist to prevent it. West London
Hospital, Hammersmith, W.6.
HAROLD BURGE.
HYPOTENSIVE ANÆSTHESIA are of great importance in increasing our understanding of physiological flow processes. It is therefore absolutely essential that observations on models are interpreted correctly and that great care is taken in extrapolating model results to live
SiR,ŁFlow experiments in models
conditions. We are prompted to make these comments by the observation of Dr. Osborn (July 20) that reducing the flow in a model of the left coronary artery converted laminar (streamline) flow to turbulence. This is contrary to experimental observations and theoretical predictions made over the past sixty years and consequently calls for some
scepticism.
We observe from the illustration of the model (fig. 2 in Dr. Osborn’s letter) that small particles were used as a tracer in the flow experiments. As a means of detecting turbulence this is rather dangerous. If the particles are slightly denser than the surrounding fluid, then at high speeds they will not follow the turbulent movement of the fluid but, owing to their greater inertia, will move uniformly in the general direction of the flow. 1. Chadwick, J., Mann, W. N. The Medical Works of Hippocrates. Oxford, 1950.