GASTRIC ULCER AND GASTRITIS
1
1075 "... in a service which deals with people, and people at their most vulnerable when they are ill, I think that it is absolutely vital that any member of Parliament on behalf of any of his constituents can get up in the House of Commons and ask me why that constituent was not properly treated at such-and-such a hospital ". These statements and sentiments are fundamentally wrong. The healthiest thing about a profession is its direct accountability to the public, and the healthiest thing about a professional training is that it teaches a man this sort of accountability. We carry this responsibility to patients fully on our own shoulders and the appearance or disappearance of the Health Service has nothing to do with it. Personal responsibility of this sort is worth a hundred of the sorts of " accountabilities " trans- mitted via members of Parliament, Ministers of Health, and Government departments, and must not be taken over by them. If the Minister wants to answer specific complaints about the specific treatment of a specific patient at a specific hospital, then he is envisaging a take-over which can be nothing less than disastrous for patients and doctors alike, and which must not happen. Complaints should be directed to and dealt with by the doctor concerned; and if the outcome is unsatisfactory the patient should be directed to the hospital medical staff com- mittee, who should I hope care enough about medicine to put the patient’s welfare before any fear of correcting a colleague. If we do not care in this way, then we are not mature enough to be doctors, let alone to be on medical committees, and it is right and proper that we should be treated as schoolchildren, sneaked on by patients, and given a wigging by teacher. My main fear, from the letters and conversations by which one learns the view of one’s colleagues, is that we have already shirked our responsibilities and allowed this sort of parlia- mentary accountability to take over. If it goes on the next generation of doctors will be unfit to take these responsibilities upon themselves, and the profession will have lost control of its conscience and will find itself (as has already been suggested) attempting to recreate a favourable public image by the pathetic varnishings of a public-relations officer. NIGEL LEGG. The Hospital for Sick Children, Great Ormond Street, London W.C.1. SIR,-It is disappointing to learn from the report of the interview that The Lancet had with the Minister of Health that he has rejected the idea of raising money by a national sweepstake. He does not say why, except that " it isn’t only a question of money " that bedevils the N.H.S. This seems poor grounds for not solving what is a huge problem, even if it is not the only one I would submit that it is the main prob- lem. There can hardly be a hospital in the country that is not crying out for funds-for rebuilding, for equipment, and for better staff accommodation. Adequate funds could solve the staff shortage as well, for they would permit reasonable salaries to be paid to medical staff, and stem the vast emigration; they would enable the nursing staff to be properly remunerated, and reduce the loss of trained nurses into industry and private work; and they would allow much more use to be made of ancillary workers such as ward clerks and technicians, leaving medical and nursing staff free for looking after patients, rather than for form-filling and other non-professional tasks. It is money alone which limits the number and quality of recruits to the last category. Imposing a small charge for treatment which, in these days, most people could meet, is a measure which much of the pro- fession-especially G.P.S.-would welcome. JAMES M. B. BURN. Romsey, Hampshire. PROLONGED COMA AFTER HEAD INJURY SIR,-In their article (Oct. 29, p. 938) Dr. Crompton and his colleagues state that the nine people whose brains they exam- ined had had no evidence of intracranial hasmatoma or of post- traumatic oedema and yet they say that there had been no lucid interval of consciousness after injury. I submit that the persis- tent loss of consciousness is sufficient evidence of itself to sup- pose that the brain may have been excessively swollen as the result of the head injury. The lesions above and below the tentorium could still be accounted for by the secondary effect of the cerebral swelling following trauma and/or asphyxia soon after injury. W. J. ATKINSON. Neurosurgical Unit, Hurstwood Park Hospital, Haywards Heath, Sussex. GASTRIC ULCER AND GASTRITIS SIR,-The letter from Dr. Anderson and Mr. Soman (Oct. 22, p. 908) interested me for several reasons, on which I should like to comment. The " earlier beliefs " on the influence of hyperacidity in the genesis of gastric and duodenal ulcer were born of the chance discovery that acid was the one factor in gastric physiology which could easily be measured. Since then " acidity " has dominated the thinking of pathologists on the subject, and in the realm of therapeutics, medical or surgical, everything which appeared to reduce gastric acidity has been considered " physiological " treatment. In the light of modern methods the " earlier beliefs " are seen to have been founded on very inadequate analytical procedures-and the more refined analyses of today produce much conflicting evidence- but " acidity " has lost none of its mystique. Dr. Anderson and Mr. Soman refer to the fact that a persisting gastritis will, in adverse circumstances, lead to chronic gastric ulcer. I am in hearty agreement, but I object to the inference that no stage exists between gastritis and chronic ulcer, with implied slur on the acute ulcer, which is infinitely more common than the chronic ulcer and is a far more potent cause of all the manifestations of the disease, including dyspepsia, haemorrhage, and perforation. Obsession with the chronic ulcer ranks with the fetish of acidity as a cause of wrong thinking on peptic disease. Dr. Anderson and Mr. Soman cite Mackay and Hislop as finding that " ulceration could heal in the presence of con- tinuing widespread gastritis ". They could as well cite the experience of every surgeon who has ever done a partial gastrectomy for peptic disease and has troubled to look at his specimen with his naked eye and microscopically. In many patients with proved ulcer this has healed by the time the operation is performed, yet in all such cases microscopic examination shows persisting gastritis. It is indeed because of the readiness with which ulcers will heal in the presence of chronic gastritis that so-called medical treatment is so frequently successful in " healing the ulcer " -but medical treatment cannot prevent the almost invariable recurrence of ulcers and symptoms. Hitherto this has been achieved only by surgical operation-partial gastrectomy achieves it by removing the more severe and irreversible gastritis in the pyloric half of the stomach. Other successful surgical methods doubtless cure or modify the chronic gastritis in some other way. FRANK FORTY. Edgware General Hospital, Middlesex. EFFECTS OF VAGOTOMY SIR,-With reference to my letter on this subject,! I should like to modify the position, as stated at that time, and to amplify it. My statement, that no case of persistent or episodic diarrhoea had been seen following selective vagotomy, was based on reports of my follow-up observers, who were referring to the incidence of serious and disabling diarrhoea. After careful per- sonal scrutiny of the notes on these patients, who had had vagotomy and pyloroplasty performed, it seems best to classify diarrhoeas into the following two types: 1. Severe diarrhcea. This is often extremely urgent, is possibly 1. Hendry, W. G. Lancet, 1966, i, 1425.
Transcript of GASTRIC ULCER AND GASTRITIS
1075
"... in a service which deals with people, and people at their mostvulnerable when they are ill, I think that it is absolutely vital thatany member of Parliament on behalf of any of his constituents can
get up in the House of Commons and ask me why that constituentwas not properly treated at such-and-such a hospital ".These statements and sentiments are fundamentally wrong.
The healthiest thing about a profession is its direct accountabilityto the public, and the healthiest thing about a professionaltraining is that it teaches a man this sort of accountability. Wecarry this responsibility to patients fully on our own shouldersand the appearance or disappearance of the Health Service hasnothing to do with it. Personal responsibility of this sort isworth a hundred of the sorts of " accountabilities " trans-mitted via members of Parliament, Ministers of Health, andGovernment departments, and must not be taken over by them.If the Minister wants to answer specific complaints about thespecific treatment of a specific patient at a specific hospital,then he is envisaging a take-over which can be nothing lessthan disastrous for patients and doctors alike, and which mustnot happen. Complaints should be directed to and dealt withby the doctor concerned; and if the outcome is unsatisfactorythe patient should be directed to the hospital medical staff com-mittee, who should I hope care enough about medicine to putthe patient’s welfare before any fear of correcting a colleague.If we do not care in this way, then we are not mature enoughto be doctors, let alone to be on medical committees, and it isright and proper that we should be treated as schoolchildren,sneaked on by patients, and given a wigging by teacher.My main fear, from the letters and conversations by which
one learns the view of one’s colleagues, is that we have alreadyshirked our responsibilities and allowed this sort of parlia-mentary accountability to take over. If it goes on the next
generation of doctors will be unfit to take these responsibilitiesupon themselves, and the profession will have lost control ofits conscience and will find itself (as has already been suggested)attempting to recreate a favourable public image by the patheticvarnishings of a public-relations officer.
NIGEL LEGG.
The Hospital for Sick Children,Great Ormond Street,
London W.C.1.
SIR,-It is disappointing to learn from the report of theinterview that The Lancet had with the Minister of Healththat he has rejected the idea of raising money by a
national sweepstake. He does not say why, except that " itisn’t only a question of money " that bedevils the N.H.S. Thisseems poor grounds for not solving what is a huge problem, evenif it is not the only one I would submit that it is the main prob-lem. There can hardly be a hospital in the country that is notcrying out for funds-for rebuilding, for equipment, and forbetter staff accommodation. Adequate funds could solve thestaff shortage as well, for they would permit reasonable salariesto be paid to medical staff, and stem the vast emigration; theywould enable the nursing staff to be properly remunerated, andreduce the loss of trained nurses into industry and private work;and they would allow much more use to be made of ancillaryworkers such as ward clerks and technicians, leaving medicaland nursing staff free for looking after patients, rather than forform-filling and other non-professional tasks. It is money alonewhich limits the number and quality of recruits to the last
category.Imposing a small charge for treatment which, in these days,
most people could meet, is a measure which much of the pro-fession-especially G.P.S.-would welcome.
JAMES M. B. BURN.Romsey,
Hampshire.
PROLONGED COMA AFTER HEAD INJURYSIR,-In their article (Oct. 29, p. 938) Dr. Crompton and his
colleagues state that the nine people whose brains they exam-ined had had no evidence of intracranial hasmatoma or of post-traumatic oedema and yet they say that there had been no lucidinterval of consciousness after injury. I submit that the persis-
tent loss of consciousness is sufficient evidence of itself to sup-pose that the brain may have been excessively swollen as theresult of the head injury. The lesions above and below thetentorium could still be accounted for by the secondary effect ofthe cerebral swelling following trauma and/or asphyxia soonafter injury.
W. J. ATKINSON.
Neurosurgical Unit,Hurstwood Park Hospital,
Haywards Heath,Sussex.
GASTRIC ULCER AND GASTRITIS
SIR,-The letter from Dr. Anderson and Mr. Soman
(Oct. 22, p. 908) interested me for several reasons, on whichI should like to comment.The " earlier beliefs " on the influence of hyperacidity in
the genesis of gastric and duodenal ulcer were born of thechance discovery that acid was the one factor in gastricphysiology which could easily be measured. Since then" acidity " has dominated the thinking of pathologists on thesubject, and in the realm of therapeutics, medical or surgical,everything which appeared to reduce gastric acidity has beenconsidered " physiological " treatment. In the light of modernmethods the " earlier beliefs " are seen to have been foundedon very inadequate analytical procedures-and the more
refined analyses of today produce much conflicting evidence-but " acidity " has lost none of its mystique.
Dr. Anderson and Mr. Soman refer to the fact that a
persisting gastritis will, in adverse circumstances, lead to
chronic gastric ulcer. I am in hearty agreement, but I objectto the inference that no stage exists between gastritis andchronic ulcer, with implied slur on the acute ulcer, which isinfinitely more common than the chronic ulcer and is a farmore potent cause of all the manifestations of the disease,including dyspepsia, haemorrhage, and perforation. Obsessionwith the chronic ulcer ranks with the fetish of acidity as acause of wrong thinking on peptic disease.
Dr. Anderson and Mr. Soman cite Mackay and Hislop asfinding that " ulceration could heal in the presence of con-tinuing widespread gastritis ". They could as well cite the
experience of every surgeon who has ever done a partialgastrectomy for peptic disease and has troubled to look at hisspecimen with his naked eye and microscopically. In manypatients with proved ulcer this has healed by the time theoperation is performed, yet in all such cases microscopicexamination shows persisting gastritis.
It is indeed because of the readiness with which ulcers willheal in the presence of chronic gastritis that so-called medicaltreatment is so frequently successful in " healing the ulcer "-but medical treatment cannot prevent the almost invariablerecurrence of ulcers and symptoms. Hitherto this has beenachieved only by surgical operation-partial gastrectomyachieves it by removing the more severe and irreversible
gastritis in the pyloric half of the stomach. Other successful
surgical methods doubtless cure or modify the chronic
gastritis in some other way.
FRANK FORTY.Edgware General Hospital,
Middlesex.
EFFECTS OF VAGOTOMY
SIR,-With reference to my letter on this subject,! I shouldlike to modify the position, as stated at that time, and toamplify it. My statement, that no case of persistent or episodicdiarrhoea had been seen following selective vagotomy, was basedon reports of my follow-up observers, who were referring to theincidence of serious and disabling diarrhoea. After careful per-sonal scrutiny of the notes on these patients, who had hadvagotomy and pyloroplasty performed, it seems best to classifydiarrhoeas into the following two types:
1. Severe diarrhcea. This is often extremely urgent, is possibly1. Hendry, W. G. Lancet, 1966, i, 1425.
