472
Journal of the Royal Society of Medicine Volume 72 June 1979
Letters to the Editor efficiency can be tested independently by other operators. One evisceration in 250 wounds closed between January 1977 and March 1978 is indeed a pleasing record. However, since nonabsorbable sutures were used in the fascial layers, Professor Ellis has missed the opportunity to give us the mathematical facts which must have been present in the one wound which failed. Did the disruption result from the intact suture cutting out from the tissues, or from knot failure, suture breakage, or from too large a stitch interval? If it was from deficiency of suture length (SL) culminating in suture cut out, what was the ratio of suture length to wound length (WL)-ratio SL:WL-which was responsible for the evisceration? Similarly, if any of the incisional hernias have come to operation for the of methods investigation 'With newer alternative repair, the ratio SL:WL responsible in each late value of the electroencephalogram (E.E.G.) must inevit- wound disruption could have been recorded. ably be questioned. Unfortunately there has been a I am cited as the principal proponent of mass tendency for the E.E.G. report to replace a thorough in this country. I do indeed use mass closure still of the depends clinical history; yet diagnosis epilepsy primarily upon an accurate history and, where possible, closure in midline wounds and also in those observation of the nature of an attack. In terms of paramedian incisions which, in error, I have placed localization of lesions the E.E.G. is of limited value if less than 1.5 cm from the medial edge of the rectus practical management rather than gradual academic sheath, where the collagen bundles lie parallel to diagnosis is the aim. Certainly in the absence of clinical each other on the medial side of the incision. localizing or lateralizing features the E.E.G. may indicate Regrettably, it was not made clear in my paper which of the more invasive techniques should be employed, but with the newer non-invasive techniques its (Jenkins 1976) that a layered closure using nylon in value in the early diagnosis of intracranial tumour will all layers except the skin is preferred. In paramedian incisions I like to open the rectus sheath continue to diminish.' 2-4 cm lateral to the edge of the linea alba. This As no neurophysiologist questioned these pre- allows 1-2 cm tissue bites which hold decussating mises in the correspondence columns of the British collagen bundles both medially and laterally. I Medical Journal, is it not reasonable to assume that certainly do advise large tissue bites placed close they are correct? Reading Dr Critchley's editorial together and I take great care to ensure that the (July 1978 Journal, p 473) and the subsequent stitch pattern is an ortho-stitch pattern which does correspondence I gain a different impression. not tolerate tissue compression and does not risk As I am concerned with the most effective use ol tissue necrosis. I try to make the length of suture inserted in each layer relate accurately to the length resources in the NHS, which am I to believe? required mathematically for the tissue bite and Yours sincerely stitch interval in use. P J BOURDILLON It has been shown that surgeons in training can 4 April 1979 also prevent evisceration and incisional hernia (Love 1979). A high ratio of SL:WL, between 4:1 and 6:1, with a stitch interval around 1 cm is Closure of the abdominal wound needed with nonabsorbable sutures of sufficient From Mr T P N Jenkins strength. This high ratio technique gives adequate Consultant Surgeon, resistance to the disruptive forces in the wound to St Luke's Hospital, Guildford, Surrey Sir, Professor Ellis reminds our profession that the prevent deep dehiscence even in the presence of ideal method of closure remains to be discovered malignant disease, jaundice, uraemia, malnu(January Journal, p 17). But even if it is discovered, trition, cytotoxic drugs and injection either in the it is likely to remain unrecognized by others so long wound or deep in the abdomen. as surgeons persist in using a craft method devoid By use of this scientific check on wound closure, of scientific check. Only accurate measurement of a we could think and speak about tissue bites, stitch method makes it exactly reproducible so that its lengths and stitch intervals as measured quantities
Electroencephalography today From Dr P J Bourdillon Department of Health and Social Security, Hannibal House, London SEI 6TE Dear Sir, Thank you for giving me the opportunity to reply to the letters of Drs Critchley, Binnie, Driver and Pampiglione (May Journal, pp 388390). Perhaps I should emphasize that my letter (February, p 154) merely quoted some of the literature that I felt was relevant to a discussion on electroencephalography today. It did not express an opinion, either that of the DHSS or myself, on the clinical value of the EEG. In 1975, an editorial in the British Medical Journal (ii, 295-296) stated the following:
Journal of the Royal Society of Medicine Volume 72 June 1979
which could be recorded and studied. Surely we should settle down to the scientific study of the various patterns of abdominal wound closure in use and the individual techniques of the surgeons who use them. As a result, we would be able to communicate with each other on our experiences of wound closure without arousing anger or just frank disbelief; hernia repair needs a similar approach. The recognition of the necessary criteria to make wound closure safe and comfortable would rapidly follow. Perhaps a method close to the ideal would be found and gain recognition within a decade. T P N JENKINS
5 April 1979
References Jenkins T P N (1976) British Journal of Surgery 63, 873-876 Love A (1979) British Journal of Surgery (in press)
Endocrine hypofunction following radiotherapy From Mr M A Coe Radiotherapy Department, Westminster Hospital, London SWI Dear Sir, The minimum information needed to compare one radiotherapy treatment course with another is the total dose, number of fractions, and total treatment time. Even then, such comparisons may not be entirely valid. The interesting review by Shalet & Beardwell entitled 'Endocrine consequences of treatment of malignant disease in childhood' (January Journal, p 39) contains eight statements of radiation dose, and in half of them only the total dose is given. None gives the full description of total dose/number of fractions/total time. I believe that the Manchester experience of endocrine hypofunction following radiotherapy has not been reproduced in every centre. This article as it stands does not allow the reader to compare the Manchester techniques with others, or persuade him to change his own practice. Yours sincerely M A COE
20 March 1979
A copy of this letter was sent to Drs Shalet and Beardwell whose reply appears below: Dear Sir, We completely agree with the point raised by Mr M A Coe that the effect of a
473
radiotherapy treatment will depend on many factors including the total dose, number of fractions and total treatment time. We (January, p 39) had to review a considerable field in a relatively short paper and therefore full details of each radiotherapy treatment were not mentioned. However, on each occasion that a radiation dose was quoted in the article there is a reference attached, and this will in many cases supply further information concerning the radiotherapy treatment. Mr Coe also mentions disagreement amongst different groups about endocrine hypofunction following radiotherapy. Contention has only existed in one area and that is whether or not abnormalities of growth hormone (GH) secretion occur in children who previously received prophylactic cranial irradiation for acute lymphatic leukaemia. Indeed, Swift et al. (1978) have suggested that the abnormality of GH secretion described by us (Shalet et al. 1977) in leukaemic children may only be a Manchester phenomenon. Similar abnormalities, however, have been found in such children in Glasgow (Barter et al. 1978), Bethesda (Oliff et al. 1979), Arkansas (Dickinson et al. 1978) and Italy (Schiliro et al. 1976). We believe that the discrepancy between the GH responses to provocative stimuli reported by different groups is almost certainly due to the variation in the effective biological dose of irradiation reaching the hypothalamic-pituitary axis. As already indicated, the latter will be influenced by the total dose, number of fractions and total treatment tinme as well as the method of irradiation and the fraction size. S M SHALET C G BEARDWELL
27 March 1979
References Barter D A C, Hamilton W & Willoughby M L N (1978) Archives of Disease in Childhood 53, 518 Dickinson W P, Berry D H, Dickinson L, Irvin M, Schedewie H, Fiser R H & Elders M J (1978) Journal of Pediatrics 92, 754 Oliff A, Bode U, Bercu B, DiChiro G, Graves V, Pizzo P, Glaubiger D, Glatstein E & Poplack D (1979) Abnormally low GH responses to insulin hypoglycaemia following CNS prophylaxis: Correlation with abnormal CT scans (in preparation) Schiliro G, Russo A, Sciotto A, Distefano G & Vigo R (1976) Lancet ii, 1031 Shalet S M, Beardwell C G, Twomey J A, Morris Jones P H & Pearson D (1977) Journal of Pediatrics 90, 920 Swift P G F, Savage D C L, Mott M G & Bullimore J A (1978) British Medical Journal ii, 986
Journal of the Royal Society of Medicine Volume 72 June 1979
Letters to the Editor efficiency can be tested independently by other operators. One evisceration in 250 wounds closed between January 1977 and March 1978 is indeed a pleasing record. However, since nonabsorbable sutures were used in the fascial layers, Professor Ellis has missed the opportunity to give us the mathematical facts which must have been present in the one wound which failed. Did the disruption result from the intact suture cutting out from the tissues, or from knot failure, suture breakage, or from too large a stitch interval? If it was from deficiency of suture length (SL) culminating in suture cut out, what was the ratio of suture length to wound length (WL)-ratio SL:WL-which was responsible for the evisceration? Similarly, if any of the incisional hernias have come to operation for the of methods investigation 'With newer alternative repair, the ratio SL:WL responsible in each late value of the electroencephalogram (E.E.G.) must inevit- wound disruption could have been recorded. ably be questioned. Unfortunately there has been a I am cited as the principal proponent of mass tendency for the E.E.G. report to replace a thorough in this country. I do indeed use mass closure still of the depends clinical history; yet diagnosis epilepsy primarily upon an accurate history and, where possible, closure in midline wounds and also in those observation of the nature of an attack. In terms of paramedian incisions which, in error, I have placed localization of lesions the E.E.G. is of limited value if less than 1.5 cm from the medial edge of the rectus practical management rather than gradual academic sheath, where the collagen bundles lie parallel to diagnosis is the aim. Certainly in the absence of clinical each other on the medial side of the incision. localizing or lateralizing features the E.E.G. may indicate Regrettably, it was not made clear in my paper which of the more invasive techniques should be employed, but with the newer non-invasive techniques its (Jenkins 1976) that a layered closure using nylon in value in the early diagnosis of intracranial tumour will all layers except the skin is preferred. In paramedian incisions I like to open the rectus sheath continue to diminish.' 2-4 cm lateral to the edge of the linea alba. This As no neurophysiologist questioned these pre- allows 1-2 cm tissue bites which hold decussating mises in the correspondence columns of the British collagen bundles both medially and laterally. I Medical Journal, is it not reasonable to assume that certainly do advise large tissue bites placed close they are correct? Reading Dr Critchley's editorial together and I take great care to ensure that the (July 1978 Journal, p 473) and the subsequent stitch pattern is an ortho-stitch pattern which does correspondence I gain a different impression. not tolerate tissue compression and does not risk As I am concerned with the most effective use ol tissue necrosis. I try to make the length of suture inserted in each layer relate accurately to the length resources in the NHS, which am I to believe? required mathematically for the tissue bite and Yours sincerely stitch interval in use. P J BOURDILLON It has been shown that surgeons in training can 4 April 1979 also prevent evisceration and incisional hernia (Love 1979). A high ratio of SL:WL, between 4:1 and 6:1, with a stitch interval around 1 cm is Closure of the abdominal wound needed with nonabsorbable sutures of sufficient From Mr T P N Jenkins strength. This high ratio technique gives adequate Consultant Surgeon, resistance to the disruptive forces in the wound to St Luke's Hospital, Guildford, Surrey Sir, Professor Ellis reminds our profession that the prevent deep dehiscence even in the presence of ideal method of closure remains to be discovered malignant disease, jaundice, uraemia, malnu(January Journal, p 17). But even if it is discovered, trition, cytotoxic drugs and injection either in the it is likely to remain unrecognized by others so long wound or deep in the abdomen. as surgeons persist in using a craft method devoid By use of this scientific check on wound closure, of scientific check. Only accurate measurement of a we could think and speak about tissue bites, stitch method makes it exactly reproducible so that its lengths and stitch intervals as measured quantities
Electroencephalography today From Dr P J Bourdillon Department of Health and Social Security, Hannibal House, London SEI 6TE Dear Sir, Thank you for giving me the opportunity to reply to the letters of Drs Critchley, Binnie, Driver and Pampiglione (May Journal, pp 388390). Perhaps I should emphasize that my letter (February, p 154) merely quoted some of the literature that I felt was relevant to a discussion on electroencephalography today. It did not express an opinion, either that of the DHSS or myself, on the clinical value of the EEG. In 1975, an editorial in the British Medical Journal (ii, 295-296) stated the following:
Journal of the Royal Society of Medicine Volume 72 June 1979
which could be recorded and studied. Surely we should settle down to the scientific study of the various patterns of abdominal wound closure in use and the individual techniques of the surgeons who use them. As a result, we would be able to communicate with each other on our experiences of wound closure without arousing anger or just frank disbelief; hernia repair needs a similar approach. The recognition of the necessary criteria to make wound closure safe and comfortable would rapidly follow. Perhaps a method close to the ideal would be found and gain recognition within a decade. T P N JENKINS
5 April 1979
References Jenkins T P N (1976) British Journal of Surgery 63, 873-876 Love A (1979) British Journal of Surgery (in press)
Endocrine hypofunction following radiotherapy From Mr M A Coe Radiotherapy Department, Westminster Hospital, London SWI Dear Sir, The minimum information needed to compare one radiotherapy treatment course with another is the total dose, number of fractions, and total treatment time. Even then, such comparisons may not be entirely valid. The interesting review by Shalet & Beardwell entitled 'Endocrine consequences of treatment of malignant disease in childhood' (January Journal, p 39) contains eight statements of radiation dose, and in half of them only the total dose is given. None gives the full description of total dose/number of fractions/total time. I believe that the Manchester experience of endocrine hypofunction following radiotherapy has not been reproduced in every centre. This article as it stands does not allow the reader to compare the Manchester techniques with others, or persuade him to change his own practice. Yours sincerely M A COE
20 March 1979
A copy of this letter was sent to Drs Shalet and Beardwell whose reply appears below: Dear Sir, We completely agree with the point raised by Mr M A Coe that the effect of a
473
radiotherapy treatment will depend on many factors including the total dose, number of fractions and total treatment time. We (January, p 39) had to review a considerable field in a relatively short paper and therefore full details of each radiotherapy treatment were not mentioned. However, on each occasion that a radiation dose was quoted in the article there is a reference attached, and this will in many cases supply further information concerning the radiotherapy treatment. Mr Coe also mentions disagreement amongst different groups about endocrine hypofunction following radiotherapy. Contention has only existed in one area and that is whether or not abnormalities of growth hormone (GH) secretion occur in children who previously received prophylactic cranial irradiation for acute lymphatic leukaemia. Indeed, Swift et al. (1978) have suggested that the abnormality of GH secretion described by us (Shalet et al. 1977) in leukaemic children may only be a Manchester phenomenon. Similar abnormalities, however, have been found in such children in Glasgow (Barter et al. 1978), Bethesda (Oliff et al. 1979), Arkansas (Dickinson et al. 1978) and Italy (Schiliro et al. 1976). We believe that the discrepancy between the GH responses to provocative stimuli reported by different groups is almost certainly due to the variation in the effective biological dose of irradiation reaching the hypothalamic-pituitary axis. As already indicated, the latter will be influenced by the total dose, number of fractions and total treatment tinme as well as the method of irradiation and the fraction size. S M SHALET C G BEARDWELL
27 March 1979
References Barter D A C, Hamilton W & Willoughby M L N (1978) Archives of Disease in Childhood 53, 518 Dickinson W P, Berry D H, Dickinson L, Irvin M, Schedewie H, Fiser R H & Elders M J (1978) Journal of Pediatrics 92, 754 Oliff A, Bode U, Bercu B, DiChiro G, Graves V, Pizzo P, Glaubiger D, Glatstein E & Poplack D (1979) Abnormally low GH responses to insulin hypoglycaemia following CNS prophylaxis: Correlation with abnormal CT scans (in preparation) Schiliro G, Russo A, Sciotto A, Distefano G & Vigo R (1976) Lancet ii, 1031 Shalet S M, Beardwell C G, Twomey J A, Morris Jones P H & Pearson D (1977) Journal of Pediatrics 90, 920 Swift P G F, Savage D C L, Mott M G & Bullimore J A (1978) British Medical Journal ii, 986
