intensity of their pain? The current consensus among anaesthetists is that neonates do feel pain and therefore deserve adequate pain relief.5 Dr Cohen and Mr Zoltie go on to describe their method of analgesia for infants between 8 and 12 weeks old. We believe that they are describing blocking the dorsal nerve of the penis. This technique is in common use among anaesthetists for surgery on the penis. It is a safe technique provided that the anaesthetist is meticulous in its use, in particular aspirating before injection and keeping to the recommended safe dose of the chosen local anaesthetic agent. There does not seem to be any reason for withholding this method of analgesia from infants below 8 weeks of age. We do not dispute that the practitioners of religious circumcisions are competent and skilled in their work, but we would emphasise that their patients probably undergo a very painful procedure and deserve adequate analgesia. W LIM T DORMAN
Department of Anaesthetics, Roval Hallamshire Hospital, Sheffield S 10 2RX I Cohen J, Zoltie N. Should religious circumcisions be performed on the NHS? BIJ 1991;302:788. (30 Miarch.) 2 Anand KJS, Hickev PR. Pain and its effects on the human neoniate and fetus. N Englj Med 1987;317:1321-7. 3 Hatch DJ. Analgesia in the neonate. B.MJ 1987;294:920. 4 Gauntlett IS. Analgesia in the neonate. Br 7 Hosp Med 19X7 Junc:5 18-9. 5 RichardsTl Can a fetus feel pain?-,. B7 1985;291:1220-1.
potent modern drugs that have a good safety record are not devoid of Pide effects and morbidity. Although surgical treatment is unpleasant in the short term, controlled trials that have compared the quality of life of patients after highly selective vagotomy with that of healthy blood donors or patients after minor surgery suggest that pylorus preserving highly selective vagotomy has no specific side effects.: As we will report to the Association of Surgeons next month, since we introduced highly selective vagotomy in Leeds in 19699 we have treated 735 patients electively for duodenal ulcer, with no deaths in hospital (one later death from pulmonary embolism) and a median recurrence rate by life table analysis of 14% after 10-20 years' follow up. There were no deaths among the patients with recurrence, and most responded well to further medical treatment without reoperation. Although it is true, as Professor AlexanderWilliams says, that admissions to hospital and operations for peptic ulcer have decreased, deaths from peptic ulcer in Britain are not diminishing. Thus the complications of haemorrhage, perforation, and pyloric stenosis continue to exact a toll on our aging population, and it is by no means clear that such complications can be treated effectively without the use of vagotomy, at least in a fair proportion of cases. The brave new world envisaged by Professor Alexander-Williams may indeed come to pass, but the results are not in, and so it seems to us vitally important that in training centres, modern pylorus preserving vagotomy should continue to be used and taught.
A requiem for vagotomy SIR,-It may be too early to sing a requiem for vagotomy, as Professor J Alexander-Williams has suggested we do.' Admittedly, duodenal ulceration always has been a medical disease that sometimes required surgical treatment, and there can be no argument that in the era of H2 blockers, De-Nol, omeprazole, and Helicobacter pylon, the balance has tipped even more decisively in favour of medical treatment. Nevertheless, surgery still has some advantages. First, there is the matter of cost. The costs of the maintenance medical treatment that is required to control acid secretion over many years is formidable, far beyond the means of poor people in India, Africa, and South America, for example. The cost advantage in favour of a quick surgical solution to the problem by highly selective vagotomy has been pointed out by Sonnenberg. Vagotomy is also more effective than medical treatment in reducing acid, healing the ulcer, and keeping it healed. Professor Alexander-Williams highlights a surgical recurrence rate of 15% to 30% but ignores many reports of recurrence rates of 10% or less after five to 10 years' follow up.'- Such recurrence rates are much lower than can be achieved even with maintenance treatment with the H, blockers, while the long term effectiveness of treatment for H pylori infection is still unknown. Certainly in the Third World reinfection with H pylori seems very likely. Furthermore, vagotomy produces an even, permanent reduction in acidpepsin attack, whereas medical treatment with the H, antagonists is likely to produce an uneven and vrariable reduction in acid and pepsin. There is also a major problem with compliance for many patients, who tend not to take their pills when they are feeling well; with vagotomv there is no such problem. Tfhe profound reduction in acid caused by omeprazole may not be desirable in humans in the long term. Parietal cell or highly selective vagotomv is very specifically targeted on the proximal two thirds to three quarters of the stomach, whereas medical treatment may not be so specific in its site of action, the drug being absorbed into the blood stream and reaching receptors in other sites in the body such as brain, bone marrow, and liver. Thus even the
968
DAVID JOHNSTON IAIN G MARTIN
Department of Surgery, General Infirmary, Leeds LS I 3EX I Alexander-Williams J. A requiem for vagotomy. BMfj 1991;302: 547-8. (9 March., 2 Sonnenberg A. Costs of medical and surgical treatment of duodenal ulccr. Gastroenterologk' 1989;96:1445-52. 3 Johnston GW, Spencer EFA, Wilkinson AJ, Kennedy TL. Proximal gastric vagotomy: follow-up at 10-12 years. Brj Surg
the beds will be used initially for NHS patients having cardiac surgery to allow essential renovation of a ward; they will then be used to tackle the unacceptable NHS waiting lists that have developed in many disciplines. We believe that this is an ethical use of facilities within the NHS, given that 638 patients currently on the waiting lists have waited longer than one year for elective orthopaedic, cardiac, urological, or general surgery. IAN D GRIFFITHS PETER D WRIGHT
Freeman Hospital, Newcastle upon Tvne NE7 7[)N I Comaish JS, Farr PM, Shuistcr S. Freeman Hospital. B.A1l
1991;302:727. (23 Mlarch.)
The new NHS SIR,-As a matter of historical accuracy, East Birmingham Hospital did not start life as Birmingham's tuberculosis hospital.' It originated as a hybrid between Little Bromwich Fever Hospital (where I did my "fevers" as an undergraduate and my wife her fever nursing training) and Yardley Green Hospital "across the road," which took tuberculosis cases and where I operated on chest cases. It is a wise child who knows his father-and possibly the origins of the hospital have now become obscured by time. This is no surprise in the seemingly endless reorganisations that have been inflicted on the NHS. I am reminded of the bitter comments of Gaius Petronius in the first century AD: "We trained, hard, but it seemed every time we were forming into teams, we would be reorganised. I was to learn later in life that we tend to meet every new situation by reorganising, and a wonderful method it can be for creating the illusion of progress while producing confusion, inefficiency and demoralisation." KEITH D ROBERTS
Birmingham B13 8LP
1991;78:20-3. 4 Jordan PH, Thornby J. Should it be parictal cell vagotomy or selective sagotomv-antrectomy for the treatment of duodenal
I
ulcer? 1Ann Surg 1987;205:572-87. 5 Korttth NM, Dua KS, Brunt PW', Mathesott NA. Comparison of highly selective sagotomy with truncal vagotomy and pvloroplasty: results at 8-15 years. Brj Surg 1990;77:70-2. 6 Stoddard CJ, Johnson AG, Duthie HL. 'lThe four to eight year results of the Shcffield trial of elective duodenal ulccr surgery -highly selectivc or truncal sagotomy? Br 7 Surg 1984;71:
International specialist meetings
779-82.
Mluller C, Engelke B, Fiedler L,
et al. How do cliical results after proximal gastric vagotomy compare with the V'isick grade pattern of healthy controls? World j Surg 1983;7:610-5. 8 Salaman JR, Harsey J, Duthie HL. Importance otf' symptoms after highly selective vagotomy. B.AJJ 1981;283:1438. 9 Johnston D, Wilkinson AR. Selective vagotomv with innervatcd antrum without drainage procedure for duodenal ulcer. Brj7Surg 1969;56:626.
7
Freeman Hospital SIR,-The letter from Dr J S Comaish and colleagues about inpatient dermatology facilities at the Freeman Hospital requires comment.' In line with the wishes of the dermatology department, Newcastle District Health Authority agreed in 1988 to centralise services at the Royal Victoria Infirmary, where the academic department, outpatient facilities, and major inpatient unit were already. The Freeman Hospital supported this rationalisation of services. Detailed plans for transferring inpatient facilities and the resources were agreed but were repeatedly deferred for reasons outside the influence of the hospital. In April 1990 the district general manager made it clear to all parties that inpatient provision would not be provided at the Freeman Hospital after March 1991, and we planned accordingly. Contrary to the view that the vacated ward will be "a private surgery ward for overseas visitors,"
t)elamothe T. East Birtningham: "thc great bureaucratic square dance" begins. BMAl 1991;302:714-8. (23 March. )
SIR,-I disagee with Dr W George Kernohan on the benefits of international specialist meetings.' It is somewhat simplistic to see them merely as means of keeping up with reports in medical journals. It is important for specialists, both those who are established and those in training, to attend meetings for reasons other than being told the latest results of research. They can exchange ideas, and research plans can be assessed by their peers. The sort of information that is not available from published reports is also available, such as forthcoming vacancies for research fellows. There is also the measure that those attending are advertising their department and institution. It could be argued that other means are available for this, but they too attract expense. Presentations are often made at specialist meetings before results are published. This enables researchers to modify their programmes so that work is not repeated unnecessarily. I would suggest that the savings from all these benefits should be taken into account when cost-benefit analyses are made. STEVEN MYINT
D)epartment of Microbiology. Univrsitv of Lciccstcr, I') Box 138, L.eiccster LEI 9HN I Kerniohan WG(,. Internatioiial
302:852. (6 April.;
specialist meetings. BAI17 1991;
BMJ VOLUME 302
20 APRIL 1991
Department of Anaesthetics, Roval Hallamshire Hospital, Sheffield S 10 2RX I Cohen J, Zoltie N. Should religious circumcisions be performed on the NHS? BIJ 1991;302:788. (30 Miarch.) 2 Anand KJS, Hickev PR. Pain and its effects on the human neoniate and fetus. N Englj Med 1987;317:1321-7. 3 Hatch DJ. Analgesia in the neonate. B.MJ 1987;294:920. 4 Gauntlett IS. Analgesia in the neonate. Br 7 Hosp Med 19X7 Junc:5 18-9. 5 RichardsTl Can a fetus feel pain?-,. B7 1985;291:1220-1.
potent modern drugs that have a good safety record are not devoid of Pide effects and morbidity. Although surgical treatment is unpleasant in the short term, controlled trials that have compared the quality of life of patients after highly selective vagotomy with that of healthy blood donors or patients after minor surgery suggest that pylorus preserving highly selective vagotomy has no specific side effects.: As we will report to the Association of Surgeons next month, since we introduced highly selective vagotomy in Leeds in 19699 we have treated 735 patients electively for duodenal ulcer, with no deaths in hospital (one later death from pulmonary embolism) and a median recurrence rate by life table analysis of 14% after 10-20 years' follow up. There were no deaths among the patients with recurrence, and most responded well to further medical treatment without reoperation. Although it is true, as Professor AlexanderWilliams says, that admissions to hospital and operations for peptic ulcer have decreased, deaths from peptic ulcer in Britain are not diminishing. Thus the complications of haemorrhage, perforation, and pyloric stenosis continue to exact a toll on our aging population, and it is by no means clear that such complications can be treated effectively without the use of vagotomy, at least in a fair proportion of cases. The brave new world envisaged by Professor Alexander-Williams may indeed come to pass, but the results are not in, and so it seems to us vitally important that in training centres, modern pylorus preserving vagotomy should continue to be used and taught.
A requiem for vagotomy SIR,-It may be too early to sing a requiem for vagotomy, as Professor J Alexander-Williams has suggested we do.' Admittedly, duodenal ulceration always has been a medical disease that sometimes required surgical treatment, and there can be no argument that in the era of H2 blockers, De-Nol, omeprazole, and Helicobacter pylon, the balance has tipped even more decisively in favour of medical treatment. Nevertheless, surgery still has some advantages. First, there is the matter of cost. The costs of the maintenance medical treatment that is required to control acid secretion over many years is formidable, far beyond the means of poor people in India, Africa, and South America, for example. The cost advantage in favour of a quick surgical solution to the problem by highly selective vagotomy has been pointed out by Sonnenberg. Vagotomy is also more effective than medical treatment in reducing acid, healing the ulcer, and keeping it healed. Professor Alexander-Williams highlights a surgical recurrence rate of 15% to 30% but ignores many reports of recurrence rates of 10% or less after five to 10 years' follow up.'- Such recurrence rates are much lower than can be achieved even with maintenance treatment with the H, blockers, while the long term effectiveness of treatment for H pylori infection is still unknown. Certainly in the Third World reinfection with H pylori seems very likely. Furthermore, vagotomy produces an even, permanent reduction in acidpepsin attack, whereas medical treatment with the H, antagonists is likely to produce an uneven and vrariable reduction in acid and pepsin. There is also a major problem with compliance for many patients, who tend not to take their pills when they are feeling well; with vagotomv there is no such problem. Tfhe profound reduction in acid caused by omeprazole may not be desirable in humans in the long term. Parietal cell or highly selective vagotomv is very specifically targeted on the proximal two thirds to three quarters of the stomach, whereas medical treatment may not be so specific in its site of action, the drug being absorbed into the blood stream and reaching receptors in other sites in the body such as brain, bone marrow, and liver. Thus even the
968
DAVID JOHNSTON IAIN G MARTIN
Department of Surgery, General Infirmary, Leeds LS I 3EX I Alexander-Williams J. A requiem for vagotomy. BMfj 1991;302: 547-8. (9 March., 2 Sonnenberg A. Costs of medical and surgical treatment of duodenal ulccr. Gastroenterologk' 1989;96:1445-52. 3 Johnston GW, Spencer EFA, Wilkinson AJ, Kennedy TL. Proximal gastric vagotomy: follow-up at 10-12 years. Brj Surg
the beds will be used initially for NHS patients having cardiac surgery to allow essential renovation of a ward; they will then be used to tackle the unacceptable NHS waiting lists that have developed in many disciplines. We believe that this is an ethical use of facilities within the NHS, given that 638 patients currently on the waiting lists have waited longer than one year for elective orthopaedic, cardiac, urological, or general surgery. IAN D GRIFFITHS PETER D WRIGHT
Freeman Hospital, Newcastle upon Tvne NE7 7[)N I Comaish JS, Farr PM, Shuistcr S. Freeman Hospital. B.A1l
1991;302:727. (23 Mlarch.)
The new NHS SIR,-As a matter of historical accuracy, East Birmingham Hospital did not start life as Birmingham's tuberculosis hospital.' It originated as a hybrid between Little Bromwich Fever Hospital (where I did my "fevers" as an undergraduate and my wife her fever nursing training) and Yardley Green Hospital "across the road," which took tuberculosis cases and where I operated on chest cases. It is a wise child who knows his father-and possibly the origins of the hospital have now become obscured by time. This is no surprise in the seemingly endless reorganisations that have been inflicted on the NHS. I am reminded of the bitter comments of Gaius Petronius in the first century AD: "We trained, hard, but it seemed every time we were forming into teams, we would be reorganised. I was to learn later in life that we tend to meet every new situation by reorganising, and a wonderful method it can be for creating the illusion of progress while producing confusion, inefficiency and demoralisation." KEITH D ROBERTS
Birmingham B13 8LP
1991;78:20-3. 4 Jordan PH, Thornby J. Should it be parictal cell vagotomy or selective sagotomv-antrectomy for the treatment of duodenal
I
ulcer? 1Ann Surg 1987;205:572-87. 5 Korttth NM, Dua KS, Brunt PW', Mathesott NA. Comparison of highly selective sagotomy with truncal vagotomy and pvloroplasty: results at 8-15 years. Brj Surg 1990;77:70-2. 6 Stoddard CJ, Johnson AG, Duthie HL. 'lThe four to eight year results of the Shcffield trial of elective duodenal ulccr surgery -highly selectivc or truncal sagotomy? Br 7 Surg 1984;71:
International specialist meetings
779-82.
Mluller C, Engelke B, Fiedler L,
et al. How do cliical results after proximal gastric vagotomy compare with the V'isick grade pattern of healthy controls? World j Surg 1983;7:610-5. 8 Salaman JR, Harsey J, Duthie HL. Importance otf' symptoms after highly selective vagotomy. B.AJJ 1981;283:1438. 9 Johnston D, Wilkinson AR. Selective vagotomv with innervatcd antrum without drainage procedure for duodenal ulcer. Brj7Surg 1969;56:626.
7
Freeman Hospital SIR,-The letter from Dr J S Comaish and colleagues about inpatient dermatology facilities at the Freeman Hospital requires comment.' In line with the wishes of the dermatology department, Newcastle District Health Authority agreed in 1988 to centralise services at the Royal Victoria Infirmary, where the academic department, outpatient facilities, and major inpatient unit were already. The Freeman Hospital supported this rationalisation of services. Detailed plans for transferring inpatient facilities and the resources were agreed but were repeatedly deferred for reasons outside the influence of the hospital. In April 1990 the district general manager made it clear to all parties that inpatient provision would not be provided at the Freeman Hospital after March 1991, and we planned accordingly. Contrary to the view that the vacated ward will be "a private surgery ward for overseas visitors,"
t)elamothe T. East Birtningham: "thc great bureaucratic square dance" begins. BMAl 1991;302:714-8. (23 March. )
SIR,-I disagee with Dr W George Kernohan on the benefits of international specialist meetings.' It is somewhat simplistic to see them merely as means of keeping up with reports in medical journals. It is important for specialists, both those who are established and those in training, to attend meetings for reasons other than being told the latest results of research. They can exchange ideas, and research plans can be assessed by their peers. The sort of information that is not available from published reports is also available, such as forthcoming vacancies for research fellows. There is also the measure that those attending are advertising their department and institution. It could be argued that other means are available for this, but they too attract expense. Presentations are often made at specialist meetings before results are published. This enables researchers to modify their programmes so that work is not repeated unnecessarily. I would suggest that the savings from all these benefits should be taken into account when cost-benefit analyses are made. STEVEN MYINT
D)epartment of Microbiology. Univrsitv of Lciccstcr, I') Box 138, L.eiccster LEI 9HN I Kerniohan WG(,. Internatioiial
302:852. (6 April.;
specialist meetings. BAI17 1991;
BMJ VOLUME 302
20 APRIL 1991
