- Email: [email protected]
TESTICULAR LEUKAEMIC INFILTRATES AT DIAGNOSIS OF ACUTE LYMPHOBLASTIC LEUKAEMIA
984
CIMETIDINE, NITROSATION, AND CANCER SIR,-Dr Reed and his colleagues (Sept. 12, p. 553) err in their reference to work by Dr David Jensen, Dr Charles Gombar, and me. Reed et al. state that "Cimetidine itself can be readily nitrosated in vitro at low pH to N-nitrosocimetidine which is a powerful mutagen in vitro as well as in vivo." As references to the powerful mutagenicity of N-nitrosocimetidine they cite two of our publications,1,2 on the methylation of DNA, in vivo and in vitro, by N-nitrosocimetidine. Nowhere do we provide experimental evidence for the mutagenicity of N-nitrosocimetidine. Fels Research Institute, School of Medicine,
Temple University, Philadelphia, Pennsylvania 19140, U.S.A.
P. N. MAGEE
SiR.—Dr Reed and his colleagues (Sept. 12, p. 550) describe gastric juice nitrosamines in various conditions, including patients cimetidine and those after gastric surgery. In 1977 a prospective endoscopic study of post-gastrecomy patients was started after disturbing reports of asymptomatic stump cancers twenty years after surgery.3,4 Endoscopic biopsies were graded for mild, moderate, and severe dysplasia. Of a group of 63 patients, an average of twenty years post-gastrectomy, 13 had moderate dysplasia but no case of early or advanced gastric cancer was found. 1 patient had severe dysplasia at six months follow-up and had a remnant gastrectomy.5 The dysplasia patients have been reviewed endoscopically every six months since then, and we have serial histology, gastric juice nitrite levels, and bacteriology in 10.6Average gastric juice pH was 7 -3, and we have found a correlation between pH and log nitrite in the whole group (p<0’001). Nitrite levels have been consistently raised in dysplasia patients (36’8±4 -5, mean±SEM) mol/1 to those levels found in patients with gastric carcinoma.7Gastric juice was colonised by bacteria, but by oral rather than colonic commensals, and all isolated species of streptococcus and staphylococcus reduced nitrate to nitrite.8 Therefore over a period of four years we have been observing a group of patients with premalignant gastric stump changes, in the presence of what may be ideal circumstances for carcinogenesis.9 No case of carcinoma or severe dysplasia warranting remnant gastrectomy has been seen during follow up. The combined effects of high intragastric pH nitrites, nitrate reducing organisms,and a gastric mucosa damaged by bile reflux would therefore need to act for a number of years before induction of invasive cancer.It is in the context of this work that we are sceptical about suggestions that short courses of cimetidine could induce carcinoma of the stomach. Nevertheless the following case report gives cause for concern. A fifty-year-old male with a long history of a proven duodenal ulcer was started on a full course of cimetidine 1 g daily in 1979 after an endoscopy, which confirmed the presence of a duodenal ulcer, there being no abnormality of the antrum. He was then managed with a maintenance dose of cimetidine 400 mg at night, except during exacerbations when he took extra tablets. He remained on cimetidine for eighteen months before admission for elective
surgery. After withdrawal of cimetidine for one week his basal secretion acid was 14-5mmol/h and his peak acid output after pentagastrin was 57-33 mmol/h. At operation, in addition to his duodenal ulcer, a malignant gastric ulcer on the lesser curve at the incisura was found and he made an uncomplicated recovery from a radical partial lower gastrectomy. Histology showed a differentiated adenocarcinoma invading the floor of the ulcer suggesting carcinoma arising in an established peptic ulcer. There were no affected lymph nodes. The occurrence of a gastric carcinoma in a patient with a known duodenal ulcer is uncommon and this tumour, like those of previous reports, arose in the antrum. 10 This one case proves nothing in the context of a possible relation between cimetidine and gastric cancer, but does emphasise the importance of careful follow-up by endoscopy and biopsy of any patient on maintenance cimetidine therapy. Department of Surgery, Bristol Royal Infirmary,
N. J. MCC. MORTENSEN
Bristol BS2 8HW
W. K. ELTRINGHAM
on
Jensen DE, Magee PN. Methylation of DNA by nitrosocimetidine in vitro. Cancer Res 1981; 41: 230-36. 2. Gombar CT, Jensen DE, Magee PN. Methylation of DNA in vivo by the nitrosoderivative of cimetidine. Proc Am Assoc Cancer Res 1981; 22: 81. 3. Schrumpf E, Serk-Hanssen A, Stadaas J, Aune S, Myren J, Osnes M. Mucosal changes in the gastric stump 20-25 years after partial gastrectomy. Lancet 1977, ii: 467 - 69. 4. Domelloff L, Eriksson S, Janunger K-G. Carcinoma and possible precancerous changes of the gastric stump after Billroth II resection. Gastroenterol 1977; 73:
GASTRIC JUICE ENZYMES AND STOMACH CANCER
SiR,—Dr Shapiro and Dr Schwabe (Aug. 22, p. 423), commenting our study which indicated a role for gastric juice enzyme measurements in the diagnosis of carcinoma of the stomach in dyspeptic patients (May 23, p. 1124), conclude that the test should not be applied indiscriminately to a population in whom the prevalence of gastric carcinoma is very low. We made no suggestion that such indiscriminate use should be made of the test. Indeed, we remain to be convinced that there is any place for screening for gastric cancer in any general population in the U.K. at present. Nevertheless, to reiterate the last paragraph of our paper, we do believe that this test may be of value as an early investigation in patients with symptoms, such as dyspepsia severe enough to warrant hospital referral, in areas with a high incidence of gastric cancer (such as South-East Wales). on
We would also stress that so-called "false-positive" results with this test should not be dismissed lightly. Radiology and endoscopic examinations of the stomach, even with biopsy, are not infallible, and very occasionally a malignant lesion can be missed by both. In one recent case treated in Cardiff, the correct diagnosis of gastric carcinoma was not made until repeat endoscopy ofapatient who had become symptomless on medical therapy, the second examination being undertaken only because the gastric juice enzymes were in the "malignant" range at the initial endoscopy. As we suggested before, it is possible that patients with unexplained high gastric juice enzymes form a group who are at increased risk of gastric cancer in the future. Until this can be proved by a prospective study we will continue to follow-up such patients very carefully. Department of Surgery, Clinical Sciences Building, Northern General Hospital, Department of Pathology, Welsh National School of Medicine, Cardiff CF4 4XN
462-68
6. 7 8.
9.
Savage A, Jones S. Histological appearances of the gastric mucosa 15-27 years after partial gaitrectomy. J Clin Pathol 1979; 32: 179-86. Mortensen NJMcC, Savage A, Jones SM. Early results of a prospective study of gastric stump dysplasia: Abstracts of Surgical Research Society. Br J Surg (in press). Ruddell WSJ, Bone ES, Hill MJ, Blendis LM, Walters CL. Gastric juice nitrite- a risk factor for cancer in the hypochlorhydnc stomach? Lancet 1976; ii: 1037-39. Mortensen NJMcC, Savage A, Jones SM, Hill MJ, Marshall RJ. Gastric juice nitrite and dysplasia after partial gastrectomy. In: Abstracts of British Society of Gastroenterology. Gut (in press). Ruddell WSJ, Bone ES, Hill MJ, Walters CL. Pathogenesis of gastric cancer in pernicious anaemia. Lancet 1978; i: 521-23.
G. T. WILLIAMS
TESTICULAR LEUKAEMIC INFILTRATES AT DIAGNOSIS OF ACUTE LYMPHOBLASTIC LEUKAEMIA
1.
5.
K. ROGERS
Sheffield S5 7AU
SiR,—Dr Kim and colleagues (Sept. 26, p. 657) found that 5 of 24 boys (21%) had testicular involvement at diagnosis of acute lymphoblasitic lelukaemia (ALL), 4 of the 5 showing resolution of the infiltrates (as detected by light microscopy) after systemic chemotherapy. Kim et al. conclude that prophylactic irradiation of the testes is
not
indicated
as
part of routine
treatment
in ALL in
boys. All the boys who had testicular involvement also had white-bloodcell (WBC) counts in excess of 25 000/µl at diagnosis, while only 3 of 16 without involvement had WBC counts greater than 25 000/1. 10. Hawker
with
PC, Muscroft TJ, Keighley MRB. Gastric cancer after cimetidine in patient negative pretreatment biopsies. Lancet 1980; i 708-09.
two
985 For patients with non-T ALL, the frequency of testicular involvement at diagnosis was 4 of 7 (57%) among patients with WBC counts greater than 25 000/1. Nesbit et al.’ have shown the strong contribution of the initial WBC count to the probability of testicular relapse. This suggests that the apparent resolution of leukaemic infiltrates after initial systemic chemotherapy does not ensure against isolated testicular recurrence and early death. Kim et al. state that "Only longitudinal studies of pre-induction and sequential post-treatment testicular biopsy specimens will deflne which set of patients are at risk for the development of testicular leukaemia and might profit from early gonadal irradiation." Since the incidence of initial testicular involvement and late testicular relapse are both associated with high initial WBC counts and massive organomegaly, we would argue that prophylactic irradiation of the testes represents an appropriate treatment in the selected group of patients at higher risk for testicular relapse. Since this group also experiences a higher incidence of bone marrow relapse, current studies may underestimate the true incidence of testicular sanctuary disease. If improvements in systemic chemotherapy result in prolonged bone marrow remissions, isolated testicular relapse may become a more significant source of leukaemic recurrence. While a longitudinal study such as that proposed by Kim et al. might identify early testicular relapse, there is no indication that early treatment of such a relapse will improve ultimate survival. There is a need for a prospective randomised study of prophylactic testicular irradiation in newly diagnosed boys with "poor prognosis" ALL. Department of Pediatrics, Memorial Sloan-Kettering
PAUL A. MEYERS MICHAEL SORELL
Cancer Center New York, N.Y. 10021, U.S.A.
RECURRENCE AND EARLY ACTIVITY AFTER GROIN HERNIA REPAIR
SIR,-The timing of return to work and full activity after groin hernia repair depends more on the advice from the surgical team than on that of the general practitioner.2Mr Bourke and his colleagues (Sept. 19, p. 623) encourage earlier return to work and hope to improve on inactivity periods of 48 (early) and 65 (control) days. The hernia series with fewest recurrences has been from the Shouldice Hospital with immediate return to mobility, office work after a few days, and even the heaviest work within a month.3 The recurrence rate depends on the surgical technique used and on the care taken by the surgeon. 70% of the final wound strength is present immediately when a non-absorbable monofilament material is used.It would seem logical to encourage early return to full activity so that the patients’ muscles support the repair. With absorbable sutures the repair becomes weaker before improving and the use of such material should be discouraged or abandoned. Since April, 1974, my surgical team has been using a simplified Shouldice technique for primary and recurrent groin herniae. A recurrence rate of 1 5% in 1400 cases (follow-up rate more than 95%) seems acceptable. Immediate mobility and return to normal activities was encouraged. Early return to work has been a little disappointing but contrasts with that achieved by Bourke et al. Of 321 employed men 175 (54%) were working in 35 days or less. The range for all 321 men was 3-112 days. 78 self-employed men, including farmers, carpenters, and plumbers provide a contrast. 27 (34%) returned in 7 days or less; 63 (80%) returned by 21 days. Perhaps they were better motivated and less restricted by the opinions of their lay advisors and general practitioners. 1 Nesbit ME, Robison LL, Ortega JA, Sather HN, Donaldson M, Hammond D. Testicular relapse in childhood lymphoblastic leukemia: Association with pretreatment patient characteristics and treatment: A report for Children’s Cancer Study Group Cancer 1980; 45: 2009-16. 2. Semmence A, Kynch J. Hernia repair and time off work in Oxford. J Roy Coll Gen Practit 1980; 30: 90-96. 3. Glasgow F. Surgical repair of inguinal and femoral hernias.Con Med Assoc J 1973; 108:
Self-employed
Employed
"
.
-
z
.
z_
..._
.,........
Weeks Time off work after hernia
repair
in 78
self-employed
and 321
employed men. Recurrences shown
by asterisk.
Many of the employed were very active at home-gardening or re-roofing their houses-before being allowed back to work. Early return to full activity can only benefit patients. It is up to the surgeon to ensure careful repair of tissues. He should also advise on the timing of return to work. The patient will decide when to go back to work, in conjunction with his general practitioner who has to sign his sickness absence certificates. At a time of high unemployment some patients are afraid to have their uncomfortable hernias repaired because they think that the expected long period off work will result in them losing their jobs. There is no evidence that lengthy rest reducess the chance of recurrence-indeed, the opposite is usually the case. even
Royal Cornwall Hospital (Treliske),
N.J. BARWELL
Truro, Cornwall TR1 3LJ
TRANSFERRING THE COMATOSE HEAD-INJURED PATIENT
SIR,-Dr Gentleman and Professor Jennett (Oct. 17, p. 853) discuss the management of unconscious head-injured patients during transport to a neurological centre, but no mention is made of controlled intermittent positive ventilation (IPPV) with- muscle relaxants and endotracheal intubation. In the district general hospitals in Reading we have since 1972 increasingly used controlled hyperventilation with muscle relaxants and endotracheal intubation in the early management of unconscious patients with head injury and have found far less hypoxaemia as a result of this change of policy. Previously there were many incidents of respiratory obstruction, inhaled vomitus, and unexpected cardiac and respiratory arrest; now these are rare, and we have had no difficulty in assessing neurological status on the Glasgow coma scale between intermittent relaxant dosage. The quiet condition of the patient with the absence of stertorous breathing and hypertonic spasms provides better conditions for the resolution of cerebral damage. It seems likely that the incidence of secondary cerebral damage will be reduced by these stable conditions. Intracranial pressure monitoring has been reported as showing a reduction in the surges in intracranial pressure that straining and extensor spasms produce. The general monitoring, routine for all IPPV patients leads to the early perception and correction of hypotension and early decisions
308-13. 4. Lichtenstein
IL, Herzikoff S, Shore JM, Gynecol Obstet 1970; 130: 685-90.
et
al. The
dynamics of wound healing. Surg
5. Ross APJ. Incidence 326-28.
of inguinal hernia recurrence. Ann Roy
CollSurg Engl 1975; 57:
CIMETIDINE, NITROSATION, AND CANCER SIR,-Dr Reed and his colleagues (Sept. 12, p. 553) err in their reference to work by Dr David Jensen, Dr Charles Gombar, and me. Reed et al. state that "Cimetidine itself can be readily nitrosated in vitro at low pH to N-nitrosocimetidine which is a powerful mutagen in vitro as well as in vivo." As references to the powerful mutagenicity of N-nitrosocimetidine they cite two of our publications,1,2 on the methylation of DNA, in vivo and in vitro, by N-nitrosocimetidine. Nowhere do we provide experimental evidence for the mutagenicity of N-nitrosocimetidine. Fels Research Institute, School of Medicine,
Temple University, Philadelphia, Pennsylvania 19140, U.S.A.
P. N. MAGEE
SiR.—Dr Reed and his colleagues (Sept. 12, p. 550) describe gastric juice nitrosamines in various conditions, including patients cimetidine and those after gastric surgery. In 1977 a prospective endoscopic study of post-gastrecomy patients was started after disturbing reports of asymptomatic stump cancers twenty years after surgery.3,4 Endoscopic biopsies were graded for mild, moderate, and severe dysplasia. Of a group of 63 patients, an average of twenty years post-gastrectomy, 13 had moderate dysplasia but no case of early or advanced gastric cancer was found. 1 patient had severe dysplasia at six months follow-up and had a remnant gastrectomy.5 The dysplasia patients have been reviewed endoscopically every six months since then, and we have serial histology, gastric juice nitrite levels, and bacteriology in 10.6Average gastric juice pH was 7 -3, and we have found a correlation between pH and log nitrite in the whole group (p<0’001). Nitrite levels have been consistently raised in dysplasia patients (36’8±4 -5, mean±SEM) mol/1 to those levels found in patients with gastric carcinoma.7Gastric juice was colonised by bacteria, but by oral rather than colonic commensals, and all isolated species of streptococcus and staphylococcus reduced nitrate to nitrite.8 Therefore over a period of four years we have been observing a group of patients with premalignant gastric stump changes, in the presence of what may be ideal circumstances for carcinogenesis.9 No case of carcinoma or severe dysplasia warranting remnant gastrectomy has been seen during follow up. The combined effects of high intragastric pH nitrites, nitrate reducing organisms,and a gastric mucosa damaged by bile reflux would therefore need to act for a number of years before induction of invasive cancer.It is in the context of this work that we are sceptical about suggestions that short courses of cimetidine could induce carcinoma of the stomach. Nevertheless the following case report gives cause for concern. A fifty-year-old male with a long history of a proven duodenal ulcer was started on a full course of cimetidine 1 g daily in 1979 after an endoscopy, which confirmed the presence of a duodenal ulcer, there being no abnormality of the antrum. He was then managed with a maintenance dose of cimetidine 400 mg at night, except during exacerbations when he took extra tablets. He remained on cimetidine for eighteen months before admission for elective
surgery. After withdrawal of cimetidine for one week his basal secretion acid was 14-5mmol/h and his peak acid output after pentagastrin was 57-33 mmol/h. At operation, in addition to his duodenal ulcer, a malignant gastric ulcer on the lesser curve at the incisura was found and he made an uncomplicated recovery from a radical partial lower gastrectomy. Histology showed a differentiated adenocarcinoma invading the floor of the ulcer suggesting carcinoma arising in an established peptic ulcer. There were no affected lymph nodes. The occurrence of a gastric carcinoma in a patient with a known duodenal ulcer is uncommon and this tumour, like those of previous reports, arose in the antrum. 10 This one case proves nothing in the context of a possible relation between cimetidine and gastric cancer, but does emphasise the importance of careful follow-up by endoscopy and biopsy of any patient on maintenance cimetidine therapy. Department of Surgery, Bristol Royal Infirmary,
N. J. MCC. MORTENSEN
Bristol BS2 8HW
W. K. ELTRINGHAM
on
Jensen DE, Magee PN. Methylation of DNA by nitrosocimetidine in vitro. Cancer Res 1981; 41: 230-36. 2. Gombar CT, Jensen DE, Magee PN. Methylation of DNA in vivo by the nitrosoderivative of cimetidine. Proc Am Assoc Cancer Res 1981; 22: 81. 3. Schrumpf E, Serk-Hanssen A, Stadaas J, Aune S, Myren J, Osnes M. Mucosal changes in the gastric stump 20-25 years after partial gastrectomy. Lancet 1977, ii: 467 - 69. 4. Domelloff L, Eriksson S, Janunger K-G. Carcinoma and possible precancerous changes of the gastric stump after Billroth II resection. Gastroenterol 1977; 73:
GASTRIC JUICE ENZYMES AND STOMACH CANCER
SiR,—Dr Shapiro and Dr Schwabe (Aug. 22, p. 423), commenting our study which indicated a role for gastric juice enzyme measurements in the diagnosis of carcinoma of the stomach in dyspeptic patients (May 23, p. 1124), conclude that the test should not be applied indiscriminately to a population in whom the prevalence of gastric carcinoma is very low. We made no suggestion that such indiscriminate use should be made of the test. Indeed, we remain to be convinced that there is any place for screening for gastric cancer in any general population in the U.K. at present. Nevertheless, to reiterate the last paragraph of our paper, we do believe that this test may be of value as an early investigation in patients with symptoms, such as dyspepsia severe enough to warrant hospital referral, in areas with a high incidence of gastric cancer (such as South-East Wales). on
We would also stress that so-called "false-positive" results with this test should not be dismissed lightly. Radiology and endoscopic examinations of the stomach, even with biopsy, are not infallible, and very occasionally a malignant lesion can be missed by both. In one recent case treated in Cardiff, the correct diagnosis of gastric carcinoma was not made until repeat endoscopy ofapatient who had become symptomless on medical therapy, the second examination being undertaken only because the gastric juice enzymes were in the "malignant" range at the initial endoscopy. As we suggested before, it is possible that patients with unexplained high gastric juice enzymes form a group who are at increased risk of gastric cancer in the future. Until this can be proved by a prospective study we will continue to follow-up such patients very carefully. Department of Surgery, Clinical Sciences Building, Northern General Hospital, Department of Pathology, Welsh National School of Medicine, Cardiff CF4 4XN
462-68
6. 7 8.
9.
Savage A, Jones S. Histological appearances of the gastric mucosa 15-27 years after partial gaitrectomy. J Clin Pathol 1979; 32: 179-86. Mortensen NJMcC, Savage A, Jones SM. Early results of a prospective study of gastric stump dysplasia: Abstracts of Surgical Research Society. Br J Surg (in press). Ruddell WSJ, Bone ES, Hill MJ, Blendis LM, Walters CL. Gastric juice nitrite- a risk factor for cancer in the hypochlorhydnc stomach? Lancet 1976; ii: 1037-39. Mortensen NJMcC, Savage A, Jones SM, Hill MJ, Marshall RJ. Gastric juice nitrite and dysplasia after partial gastrectomy. In: Abstracts of British Society of Gastroenterology. Gut (in press). Ruddell WSJ, Bone ES, Hill MJ, Walters CL. Pathogenesis of gastric cancer in pernicious anaemia. Lancet 1978; i: 521-23.
G. T. WILLIAMS
TESTICULAR LEUKAEMIC INFILTRATES AT DIAGNOSIS OF ACUTE LYMPHOBLASTIC LEUKAEMIA
1.
5.
K. ROGERS
Sheffield S5 7AU
SiR,—Dr Kim and colleagues (Sept. 26, p. 657) found that 5 of 24 boys (21%) had testicular involvement at diagnosis of acute lymphoblasitic lelukaemia (ALL), 4 of the 5 showing resolution of the infiltrates (as detected by light microscopy) after systemic chemotherapy. Kim et al. conclude that prophylactic irradiation of the testes is
not
indicated
as
part of routine
treatment
in ALL in
boys. All the boys who had testicular involvement also had white-bloodcell (WBC) counts in excess of 25 000/µl at diagnosis, while only 3 of 16 without involvement had WBC counts greater than 25 000/1. 10. Hawker
with
PC, Muscroft TJ, Keighley MRB. Gastric cancer after cimetidine in patient negative pretreatment biopsies. Lancet 1980; i 708-09.
two
985 For patients with non-T ALL, the frequency of testicular involvement at diagnosis was 4 of 7 (57%) among patients with WBC counts greater than 25 000/1. Nesbit et al.’ have shown the strong contribution of the initial WBC count to the probability of testicular relapse. This suggests that the apparent resolution of leukaemic infiltrates after initial systemic chemotherapy does not ensure against isolated testicular recurrence and early death. Kim et al. state that "Only longitudinal studies of pre-induction and sequential post-treatment testicular biopsy specimens will deflne which set of patients are at risk for the development of testicular leukaemia and might profit from early gonadal irradiation." Since the incidence of initial testicular involvement and late testicular relapse are both associated with high initial WBC counts and massive organomegaly, we would argue that prophylactic irradiation of the testes represents an appropriate treatment in the selected group of patients at higher risk for testicular relapse. Since this group also experiences a higher incidence of bone marrow relapse, current studies may underestimate the true incidence of testicular sanctuary disease. If improvements in systemic chemotherapy result in prolonged bone marrow remissions, isolated testicular relapse may become a more significant source of leukaemic recurrence. While a longitudinal study such as that proposed by Kim et al. might identify early testicular relapse, there is no indication that early treatment of such a relapse will improve ultimate survival. There is a need for a prospective randomised study of prophylactic testicular irradiation in newly diagnosed boys with "poor prognosis" ALL. Department of Pediatrics, Memorial Sloan-Kettering
PAUL A. MEYERS MICHAEL SORELL
Cancer Center New York, N.Y. 10021, U.S.A.
RECURRENCE AND EARLY ACTIVITY AFTER GROIN HERNIA REPAIR
SIR,-The timing of return to work and full activity after groin hernia repair depends more on the advice from the surgical team than on that of the general practitioner.2Mr Bourke and his colleagues (Sept. 19, p. 623) encourage earlier return to work and hope to improve on inactivity periods of 48 (early) and 65 (control) days. The hernia series with fewest recurrences has been from the Shouldice Hospital with immediate return to mobility, office work after a few days, and even the heaviest work within a month.3 The recurrence rate depends on the surgical technique used and on the care taken by the surgeon. 70% of the final wound strength is present immediately when a non-absorbable monofilament material is used.It would seem logical to encourage early return to full activity so that the patients’ muscles support the repair. With absorbable sutures the repair becomes weaker before improving and the use of such material should be discouraged or abandoned. Since April, 1974, my surgical team has been using a simplified Shouldice technique for primary and recurrent groin herniae. A recurrence rate of 1 5% in 1400 cases (follow-up rate more than 95%) seems acceptable. Immediate mobility and return to normal activities was encouraged. Early return to work has been a little disappointing but contrasts with that achieved by Bourke et al. Of 321 employed men 175 (54%) were working in 35 days or less. The range for all 321 men was 3-112 days. 78 self-employed men, including farmers, carpenters, and plumbers provide a contrast. 27 (34%) returned in 7 days or less; 63 (80%) returned by 21 days. Perhaps they were better motivated and less restricted by the opinions of their lay advisors and general practitioners. 1 Nesbit ME, Robison LL, Ortega JA, Sather HN, Donaldson M, Hammond D. Testicular relapse in childhood lymphoblastic leukemia: Association with pretreatment patient characteristics and treatment: A report for Children’s Cancer Study Group Cancer 1980; 45: 2009-16. 2. Semmence A, Kynch J. Hernia repair and time off work in Oxford. J Roy Coll Gen Practit 1980; 30: 90-96. 3. Glasgow F. Surgical repair of inguinal and femoral hernias.Con Med Assoc J 1973; 108:
Self-employed
Employed
"
.
-
z
.
z_
..._
.,........
Weeks Time off work after hernia
repair
in 78
self-employed
and 321
employed men. Recurrences shown
by asterisk.
Many of the employed were very active at home-gardening or re-roofing their houses-before being allowed back to work. Early return to full activity can only benefit patients. It is up to the surgeon to ensure careful repair of tissues. He should also advise on the timing of return to work. The patient will decide when to go back to work, in conjunction with his general practitioner who has to sign his sickness absence certificates. At a time of high unemployment some patients are afraid to have their uncomfortable hernias repaired because they think that the expected long period off work will result in them losing their jobs. There is no evidence that lengthy rest reducess the chance of recurrence-indeed, the opposite is usually the case. even
Royal Cornwall Hospital (Treliske),
N.J. BARWELL
Truro, Cornwall TR1 3LJ
TRANSFERRING THE COMATOSE HEAD-INJURED PATIENT
SIR,-Dr Gentleman and Professor Jennett (Oct. 17, p. 853) discuss the management of unconscious head-injured patients during transport to a neurological centre, but no mention is made of controlled intermittent positive ventilation (IPPV) with- muscle relaxants and endotracheal intubation. In the district general hospitals in Reading we have since 1972 increasingly used controlled hyperventilation with muscle relaxants and endotracheal intubation in the early management of unconscious patients with head injury and have found far less hypoxaemia as a result of this change of policy. Previously there were many incidents of respiratory obstruction, inhaled vomitus, and unexpected cardiac and respiratory arrest; now these are rare, and we have had no difficulty in assessing neurological status on the Glasgow coma scale between intermittent relaxant dosage. The quiet condition of the patient with the absence of stertorous breathing and hypertonic spasms provides better conditions for the resolution of cerebral damage. It seems likely that the incidence of secondary cerebral damage will be reduced by these stable conditions. Intracranial pressure monitoring has been reported as showing a reduction in the surges in intracranial pressure that straining and extensor spasms produce. The general monitoring, routine for all IPPV patients leads to the early perception and correction of hypotension and early decisions
308-13. 4. Lichtenstein
IL, Herzikoff S, Shore JM, Gynecol Obstet 1970; 130: 685-90.
et
al. The
dynamics of wound healing. Surg
5. Ross APJ. Incidence 326-28.
of inguinal hernia recurrence. Ann Roy
CollSurg Engl 1975; 57: