- Email: [email protected]
VITAMIN E AND INTERMITTENT CLAUDICATION
597 bya large amount depending on hut irrespective of the prevailing
mortality.
the
severity of the fog morbidity and
level of
J. A. SCOTT Medical Officer of Health, County of London. PAID
SICK-LEAVE
not be generally known that the Staffs Council for the Whitley Council for the Health Service of Great Britain have fairly recently come to a very important decision concerning entitleThis states quite ment to sick-pay of ancillary staffs. from before becoming as Jan. that, 1, 1953, clearly entitled to benefit under the scheme an employee shall (a) complete six calendar months’ continuous service, and (b) submit, if so required (by the employing authority), to a medical examination by a registered medical practitioner nominated by the employing authority, and be recommended by such medical practitioner for admission to the scheme. It will be appreciated that if the hospital management committee decides that all ancillary staffs " appointed after Jan. 1, 1953, must undergo such a medical examination, one important point must be decided-i.e., who is the best medical practitioner to undertake the examination Should it be the employee’s general practitioner, who knows the employee well, or should it be an independent practitioner who may be a member of the hospital staff ? There is no doubt that the Ministry of Health, through the Whitley Council, are well aware that the sick-pay scheme is open to abuse, and are trying to overcome the inherent difficulties. The recent circular forwarding the decisions of the Whitley Council also suggests that it may be useful to calculate the approximate average amount disbursed weekly in sick-pay, whether certified or uncertified ; and this information will be very
SIR,—It may
Ancillary
"
revealing. Pontefract and Castleford Hospital
Management Committee, Pontefract.
W. BOWRING.
VITAMIN E AND INTERMITTENT CLAUDICATION
SIR,-Three years ago, in a paperfrom Professor Boyd’s department, it was reported that, of 41 patients suffering from intermittent claudication and treated
’with vitamin E, 34 showed improvement after only three months’ treatment, as compared with 5 out of 25 controls." The vitamin E was given in smaller doses than we have used.2 In limiting the duration of treatment in our trial to three months we were partly Professor Boyd and his influenced by these claims. now advocate six months’ con(March 7) colleagues tinuous treatment, despite their previous experience. An increase in exercise tolerance of patients suffering from intermittent claudication is generally accepted as indicating a dilatation of previously existing vessels, or alternatively the development of new collateral channels. If it is accepted that vitamin E acts by either of these methods then vascular changes resulting from its administration should occur independently of any test used to measure progress. If a patient is grade 11 hy Professor Boyd’s testing, even though he may be grade III on our test, then he should be expected to pond to treatment with vitamin E, if it is effective. ..
Moreover,
we have analysed the results for the 20 patients trial who were less severely affected (grade II). The mean increase in the average number of circuits walked during the treatment period, compared with the pretreatment period, was 1-05 :r: 1-38 for 11patients treated with vitamin E, and 1.84± 1-52 for 9 controls. The mean increase in the average number walked during the three months following in our
1. 2.
Rateliffe, A. H. Lancet, 1949, ii, 1128. Hamilton, M., Wilson, G. M., Armitage, P., Boyd, Feb. 21, 1953, p. 367.
J. T.
Ibid,
the end of treatment, compared with the pretreatment period, 0-66 1-34 for the vitamin-E group and 1.76 ± 1-48 for the controls. Thus, even in this group of less severely affected patients there is no evidence that vitamin E was effective in increasing the exercise tolerance. was
We would remind Dr. Shute and Mr. Shute (March 7) that in a therapeutic trial conducted on the " double blind " principle, such as we advocated for vitamin E, effective remedies will still prove effective as compared with an inert substance, even though neither patient nor clinical observer is aware of the substance received by each patient. We have no doubt that both insulin and liver would have proved their value in the treatment of diabetes and pernicious anaemia respectively under The fact that vitamin E did not these conditions. survive this test in the treatment of intermittent claudication is our reason for claiming that it is an ineffective remedy in this condition. Nor do we doubt that ten observers have claimed it to be an effective treatment ; as we pointed out in our paper, many trials of this drug have been reported but unfortunately these have been characterised by the absence of controls, and have not been conducted along the lines which we advocate. Had they been so conducted the controversy mentioned by Professor Boyd and his colleagues need not now exist. M. HAMILTON G. M. WILSON P. ARMITAGE J. T. BOYD. INTUSSUSCEPTION have read with interest your leading article SIR,—We (Jan. 31) and the critical comments by Mr. Jones and his colleagues (Feb. 21). We have recently completed a review of 106 cases of acute intussusception in childhood admitted under our care during the past 31/2 years. In this series there was 1 death. In our opinion, the operative mortality for reducible intussusceptions should approach zero. Occasional deaths will occur in two types of cases : 1. Where reduction is very difficult and time-consuming and the surgeon has to decide whether to persevere with his efforts or proceed to resection. 2. The moribund case with gangrenous bowel, extreme distension, and pronounced dehydration and electrolyte imbalance which does not respond to intestinal decompression and intravenous infusion therapy carried out over several hours. Here the surgeon has to decide between continuing medical therapy in the hope of making the patient fit for operation, or risking operation in order to remove a length of gangrenous intestine.
In both these types of case applying hydrostatic pressure will only cause delay and do harm, and we can therefore see no point in using this method. We agree with Mr. Jones and his colleagues that the main reason for the fall in the mortality from intussusception (to 1% in their series) is the better management of preoperative and postoperative fluid and electrolyte deficiencies. We consider that a general fall in the mortality to a level of 1% will only be achieved when children are treated in hospitals specially equipped and staffed for paediatric surgery. We in Liverpool have not been so fortunate as the Newcastle workers in getting cases early. The average duration of symptoms in our series was 34 hours, and 273% of the children were admitted with symptoms of over 48 hours’ duration. We too have found that the symptoms are surprisingly In our series vomiting occurred in 82-1%,.f constant. in 83%, and attacks of pallor in a further 13-2%. Blood was passed in only 67.9% of cases. As regards surgical technique, we too are of the opinion that a right lower paramedian incision just long enough to admit two fingers is better than an incision in the right iliac fossa, and that it is unnecessary and
pain
mortality.
the
severity of the fog morbidity and
level of
J. A. SCOTT Medical Officer of Health, County of London. PAID
SICK-LEAVE
not be generally known that the Staffs Council for the Whitley Council for the Health Service of Great Britain have fairly recently come to a very important decision concerning entitleThis states quite ment to sick-pay of ancillary staffs. from before becoming as Jan. that, 1, 1953, clearly entitled to benefit under the scheme an employee shall (a) complete six calendar months’ continuous service, and (b) submit, if so required (by the employing authority), to a medical examination by a registered medical practitioner nominated by the employing authority, and be recommended by such medical practitioner for admission to the scheme. It will be appreciated that if the hospital management committee decides that all ancillary staffs " appointed after Jan. 1, 1953, must undergo such a medical examination, one important point must be decided-i.e., who is the best medical practitioner to undertake the examination Should it be the employee’s general practitioner, who knows the employee well, or should it be an independent practitioner who may be a member of the hospital staff ? There is no doubt that the Ministry of Health, through the Whitley Council, are well aware that the sick-pay scheme is open to abuse, and are trying to overcome the inherent difficulties. The recent circular forwarding the decisions of the Whitley Council also suggests that it may be useful to calculate the approximate average amount disbursed weekly in sick-pay, whether certified or uncertified ; and this information will be very
SIR,—It may
Ancillary
"
revealing. Pontefract and Castleford Hospital
Management Committee, Pontefract.
W. BOWRING.
VITAMIN E AND INTERMITTENT CLAUDICATION
SIR,-Three years ago, in a paperfrom Professor Boyd’s department, it was reported that, of 41 patients suffering from intermittent claudication and treated
’with vitamin E, 34 showed improvement after only three months’ treatment, as compared with 5 out of 25 controls." The vitamin E was given in smaller doses than we have used.2 In limiting the duration of treatment in our trial to three months we were partly Professor Boyd and his influenced by these claims. now advocate six months’ con(March 7) colleagues tinuous treatment, despite their previous experience. An increase in exercise tolerance of patients suffering from intermittent claudication is generally accepted as indicating a dilatation of previously existing vessels, or alternatively the development of new collateral channels. If it is accepted that vitamin E acts by either of these methods then vascular changes resulting from its administration should occur independently of any test used to measure progress. If a patient is grade 11 hy Professor Boyd’s testing, even though he may be grade III on our test, then he should be expected to pond to treatment with vitamin E, if it is effective. ..
Moreover,
we have analysed the results for the 20 patients trial who were less severely affected (grade II). The mean increase in the average number of circuits walked during the treatment period, compared with the pretreatment period, was 1-05 :r: 1-38 for 11patients treated with vitamin E, and 1.84± 1-52 for 9 controls. The mean increase in the average number walked during the three months following in our
1. 2.
Rateliffe, A. H. Lancet, 1949, ii, 1128. Hamilton, M., Wilson, G. M., Armitage, P., Boyd, Feb. 21, 1953, p. 367.
J. T.
Ibid,
the end of treatment, compared with the pretreatment period, 0-66 1-34 for the vitamin-E group and 1.76 ± 1-48 for the controls. Thus, even in this group of less severely affected patients there is no evidence that vitamin E was effective in increasing the exercise tolerance. was
We would remind Dr. Shute and Mr. Shute (March 7) that in a therapeutic trial conducted on the " double blind " principle, such as we advocated for vitamin E, effective remedies will still prove effective as compared with an inert substance, even though neither patient nor clinical observer is aware of the substance received by each patient. We have no doubt that both insulin and liver would have proved their value in the treatment of diabetes and pernicious anaemia respectively under The fact that vitamin E did not these conditions. survive this test in the treatment of intermittent claudication is our reason for claiming that it is an ineffective remedy in this condition. Nor do we doubt that ten observers have claimed it to be an effective treatment ; as we pointed out in our paper, many trials of this drug have been reported but unfortunately these have been characterised by the absence of controls, and have not been conducted along the lines which we advocate. Had they been so conducted the controversy mentioned by Professor Boyd and his colleagues need not now exist. M. HAMILTON G. M. WILSON P. ARMITAGE J. T. BOYD. INTUSSUSCEPTION have read with interest your leading article SIR,—We (Jan. 31) and the critical comments by Mr. Jones and his colleagues (Feb. 21). We have recently completed a review of 106 cases of acute intussusception in childhood admitted under our care during the past 31/2 years. In this series there was 1 death. In our opinion, the operative mortality for reducible intussusceptions should approach zero. Occasional deaths will occur in two types of cases : 1. Where reduction is very difficult and time-consuming and the surgeon has to decide whether to persevere with his efforts or proceed to resection. 2. The moribund case with gangrenous bowel, extreme distension, and pronounced dehydration and electrolyte imbalance which does not respond to intestinal decompression and intravenous infusion therapy carried out over several hours. Here the surgeon has to decide between continuing medical therapy in the hope of making the patient fit for operation, or risking operation in order to remove a length of gangrenous intestine.
In both these types of case applying hydrostatic pressure will only cause delay and do harm, and we can therefore see no point in using this method. We agree with Mr. Jones and his colleagues that the main reason for the fall in the mortality from intussusception (to 1% in their series) is the better management of preoperative and postoperative fluid and electrolyte deficiencies. We consider that a general fall in the mortality to a level of 1% will only be achieved when children are treated in hospitals specially equipped and staffed for paediatric surgery. We in Liverpool have not been so fortunate as the Newcastle workers in getting cases early. The average duration of symptoms in our series was 34 hours, and 273% of the children were admitted with symptoms of over 48 hours’ duration. We too have found that the symptoms are surprisingly In our series vomiting occurred in 82-1%,.f constant. in 83%, and attacks of pallor in a further 13-2%. Blood was passed in only 67.9% of cases. As regards surgical technique, we too are of the opinion that a right lower paramedian incision just long enough to admit two fingers is better than an incision in the right iliac fossa, and that it is unnecessary and
pain