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Journal of the Royal Society of Medicine Volume 72 May 1979

References Binnie C D, Batchelor B G, Bowring P A, Darby C E, Herbert L, Lloyd D S L, Smith D M, Smith G F & Smith M (1978) Electroencephalography and Clinical Neurophysiology 44, 575-585 Dumermuth G (1965) Elektroenkephalographie im Kindesalter. Thieme Verlag, Stuttgart Gibbs E L & Gibbs F A (1951) Neurology 1, 136-144 Hopkins A & Scambler G (1977) Lancet i, 183-186 Jeavons P M (1975) Update 10, 269-280 Kiloh L G, McComas A J & Osselton J W (1972) Clinical Electroencephalography. 3rd edn. Butterworths, London Laget P & Salbreux R (1967) Atlas d'electroencephalographie infantile. Masson, Paris O'Connor P (1964) Electroencephalography and Clinical Neurophysiology 17, 341 Robin J J, Tolan G D & Arnold J W (1978) Aviation, Space and Environmental Medicine 49, 732-736 Roubicek J, Volavka J & Matousek M (I1967) eeskoslovenska psychiatrie 63, 14-19

Diagnosis of dyslexia From Mrs Beve Hornsby Head, Dyslexia Clinic, St Bartholomew's Hospital, London ECI Sir, Further to Dr White Franklin's review (March Journal, p 234) of the book 'Dyslexia Defined' by M & E A Critchley, I would agree that diagnosis is important in that it should lead to suitable management, treatment and some indication as to prognosis. However, I feel that subdividing dyslexias into primary and secondary has tended to make diagnosis more difficult and to confuse the matter further. Although it is quite understood that there are these two distinctions - in that primary dyslexia is genetically determined and typically has a familial incidence, and secondary dyslexia is usually the result of minimal brain dysfunction - the two conditions are not easily separated, since congenital only means existing at or present from birth and could well be due to an inherited condition or to some cerebral trauma, either in utero or during birth. I cannot agree with Dr Macdonald Critchley that his definition of primary dyslexia does not include speech and language delay, poor coordination, left/right confusion, occasional difficulties with arithmetic, severe difficulties in spelling and possible problems in constructional tasks, which is Michael Rutter's definition of specific reading retardation, since all the above are often present in developmental dyslexia, whatever the aetiology. A further dimension in differential diagnosis has been added recently, in that many psychologists now talk not only about primary and secondary dyslexia, but also about deep dyslexia. It seems inappropriate to try to make differential diagnoses between these various dyslexias when what is really needed is treatment, and an accepted method has

been developed over the last 40 years, culled from America, Australia, France and Denmark, which is indisputably effective in the vast majority of cases of specific reading, spelling and writing difficulties. BEVE HORNSBY

6 March 1979

Randomized clinical trials in cancer chemotherapy From Dr Dennis V Razis Head, Department of Medicine, Cancer Institute of Piraeus, Greece Sir, When cancer chemotherapy is really effective, are randomized clinical trials necessary? The breakthroughs in modern cancer chemotherapy were not the products of prospective randomized clinical trials. High-dose-pulse methotrexate therapy in choriocarcinoma and Burkitt's tumour (Li et al. 1956, Burkitt 1967), combination chemotherapy in acute lymphoblastic leukaemia in children (Freireich et al. 1964), MOPP scheme in Hodgkin's disease (De Vita & Serpick 1967), COP scheme in non-Hodgkin's lymphoma, '5-day 5drug' regimen in carcinoma of the breast (Cooper 1969), were all products of nonrandomized clinical trials. No one ever thought to compare the results of these schemes with a group of patients treated only with placebo. It is apparent that when cancer chemotherapy is really effective, randomized clinical trials are not necessary. Why then do we need randomized clinical trials? It seems that clinical trials are useful - or even necessary - in order to demonstrate the degree of ineffectiveness of a new drug or a new combination scheme; or - to put it another way - clinical trials can prove that a new drug or a new combination scheme has a 'minimal' or at best a 'moderate' effectiveness, thus justifying the routine application in practice of this new mode of treatment. No randomized clinical trials ever proved that a new drug or a new scheme was really, dramatically effective. Clinical trials are also useful for testing a new scheme when the classical effective chemotherapy is no longer effective, for example ABVD when Hodgkin's disease becomes resistant to MOPP (Bonadonna et al. 1975). Finally, randomized clinical trials raise conceptually-scientific clinical research above the muddle of empiricism. But can we compare the impact in clinical medicine of the modest results of randomized clinical trials, such as combination chemotherapy in carcinoma of the bowel, or even adjuvant chemotherapy in carcinoma of the breast, with the impressive breakthroughs of some nonrandomized clinical trials such as methotrexate in choriocarcinoma, MOPP in Hodgkin's disease, etc.? The productivity of randomized clinical trials is only modest. This productivity must be compared

Journal of the Royal Society of Medicine Volume 72 May 1979 with the manpower, time and money spent, in order to evaluate how much emphasis should be given to randomized and nonrandomized clinical trials. It should be noted that some major cancer centres in the USA do not usually work with prospective randomized clinical trials. Other roads in clinical research could also be explored. There are exceptional responses of various generalized malignant neoplasms to chemotherapy and/or hormonotherapy, and there is no apparent explanation for these unusual responses. Clinical studies of these exceptional responses might lead to better design of future therapeutic regimens, more knowledge of the natural course of these diseases, or give clues with respect to interactions between chemotherapy and/or hormonotherapy and host immune reactions (Razis et al. 1976). Other, more productive and perhaps less expensive clinical projects should also be explored. A re-evaluation of the strategy for clinical cancer research should prove very useful.

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additional benefit of measurement is that it should provide a scientific means of comparing different methods and suture materials. I am sure others who have seen the results of Jenkins' technique would join me in advocating that any surgeon who operates on the abdomen should read this paper carefully and consider following his method. Yours faithfully R D SPICER

13 February 1979

DENNIS V RAZIS

A copy of this letter was sent to Professor Ellis, whose reply appears below: Dear Sir, In a short paper incorporating several years of work it is impossible to mention every point. We completely agree with the importance of Jenkins' work and, indeed, meticulous notes are kept of the length and depth of the wound, the length of suture employed and the numbers of knots incorporated into the wound. Yours sincerely

23 February 1979

HAROLD ELLIS

References Bonadonna G, Zucali R, Monfardini S, DeLena M & Uslenghi C (1975) Cancer 36, 252 Burkitt D P (1967) Cancer 20, 756 Cooper R G (1969) Proceedings of the American Associationfor Cancer Research 10, 15 De Vita V T jr & Serpick A (1967) Proceedings of the American Association for Cancer Research 8, 13 Freireich E J, Karon M & Frei E III (1964) Proceedings of the American Association for Cancer Research 5, 20 Li M C, Hertz R & Spencer D B (1956) Proceedings of the Society for Experimental Biology and Medicine 93, 361 Razis D V, Constandoulakis M, Dimitriades M, Athanassiou A & Messaropoulos Th (1976) Chemotherapy 8, 249

Closure of the abdominal wound From Mr R D Spicer St George's Hospital, London SWI 7 Dear Sir, The paper by Ellis & Heddle (January Journal, p 17) unfortunately misses the main point of Jenkins' important work on this subject (1976, British Journal of Surgery 63, 873-876). Jenkins showed that the burst abdomen is entirely preventable by careful technique. The cornerstone of this technique is not mass closure (indeed, his paramedian wounds were usually closed in two layers) but measurement of the length of suture inserted and the length of the fascial wound. When this is calculated as a ratio it provides a measurable yardstick for the surgeon, whether experienced or inexperienced, to judge the security of his wound closure, and if he does this then the only other requirement is that he should tie a secure knot. An

6 March 1979

Arthroscopy: the first hundred are the worst From Mr M A Edgar The Middlesex Hospital, London WIN 8AA Dear Sir, I was interested to read the paper by Bedford et al. in your January issue (p 6). I am in full agreement that the average surgeon requires the experience of a hundred knee arthroscopies before he gains confidence about the findings and, more important, before he knows the limitations of the technique. This does raise the question of how orthopaedic surgeons can best be trained so that an arthroscopy service can be provided in most orthopaedic units. The paper also comments on a few of the weaknesses of arthroscopy. In particular, there was a significant proportion of false negative findings associated with a peripheral tear of the posterior horn of the medial meniscus. .At the Orthopaedic Department of The Middlesex Hospital, in conjunction with our Athletics Clinic, we have found from recent statistics that arthroscopy has a diagnostic accuracy of about 90%O and, overall, is superior to clinical assessment and arthrography. The exception has been false negative findings in posterior horn tears of the medial meniscus, the proportion of which are similar to those reported by Bedford et al. At present, when the diagnosis is suspected clinically, it is probably more reliable to confirm it by arthrography rather than by arthroscopy. There is no doubt that the peripheral part of the medial posterior horn is the most difficult to view with the arthroscope and, unlike Bedford et al., I gain little help by externally trying to push the

Randomized clinical trials in cancer chemotherapy.

390 Journal of the Royal Society of Medicine Volume 72 May 1979 References Binnie C D, Batchelor B G, Bowring P A, Darby C E, Herbert L, Lloyd D S L...
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