445
Hysterectomy or what? is the definitive treatment for excessive loss because menstrual drug treatment is at best only temporarily effective. In the UK it is estimated that 40 000 hysterectomies are done yearly for this reason, at a cost of over £ 60 million. The development of an effective, and less hazardous, radical, and costly remedy is therefore highly desirable. Various hysteroscopic techniques for endometrial ablation have lately been advocated,
SIR,-Hysterectomy
including diathermy,’1 cryosurgery ,2 laser3 electromagnetic radiation,4 and resection.5 We have contrasted6 the lack of control over the introduction of surgical techniques compared with the rigorous testing necessary for new drugs. In your July 21 editorial you comment further on this issue, and raise some important questions about the validity and practicality of our prospective, randomised, controlled trial of hysterectomy versus transcervical resection of the endometrium. There should be no disagreement that evaluation of new surgical procedures is necessary, but attitudes towards such techniques and their evaluation are less than objective. For example, you suggest that "if it stands to reason that the new procedure is indeed less risky" then it might not be necessary to go through "the motions of a randomised trial". The earliest ablative procedure was first reported as recently as 19837and all subsequent reports are of small series followed up for a short time. One cannot, therefore, assume that they are accompanied by less risk than hysterectomy until that is properly assessed. That is one aim of our trial. You repeat a frequently expressed pejorative attitude towards randomised, controlled trials when you write of a woman being asked "to sacrifice her womb on the altar of science when a less mutilating alternative is available". The fact of the matter is that hysterectomy is the only proven method to deal effectively with excessive menstrual loss: any new method must therefore be compared against it, and it is unethical to do anything other than compare them scientifically and objectively. The proper area for debate is how best to achieve such comparison for this or any surgical procedures, and full analysis of that requires a wider forum. After due consideration and with the consent of our local ethics committee we have embarked on a randomised, controlled trial to compare hysterectomy with transcervical resection of the endometrium, with the end-points of immediate, short, and long-term risks associated with the procedures, their relative effectiveness, and patient satisfaction. In discussion of our design we considered a third "non-treatment" arm but decided against it because it was not a true new
placebo. At the time of writing over 90 of the required 200 been recruited, a response that we find encouraging.
Department of Obstetrics and Gynaecology, Bristol Maternity Hospital, Bristol BS2 8EG, UK
women
have
GORDON M. STIRRAT NUALA DWYER JAMES BROWNING
1 Vancaille TG Electrocoagulation of the endometrium with the ball-end resectoscope. Obstet Gynecol 1989; 74: 425-27. 2 Davies WAR, Pollard W, Basterfield P. Reduction of menstrual blood loss with endometnal cryosurgery. J Obstet Gynaecol 1985; 6: 117-19. 3. Davies J Hysteroscopic endometrial ablation with the neidymium-YAG laser. Br J Obstet Gynaecol 1989, 96: 928-32. 4 Phipps JH, Lewis BV, Roberts T, et al. Treatment of functional menorrhagia by radiofrequency-induced thermal endometrial ablation. Lancet 1990; 335: 374-76. 5 Magos AL, Baumann R, Tumbull AC Transcervical resection of the endometrium in women with menorrhagia. Br Med J 1989; 298: 1209-12 6 Stirrat GM, Dwyer N, Browning J. Planned trial of transcerervical resection of the endometrium versus hysterectomy. Br J Obstet Gynaecol 1990; 97: 459. 7 De Cherney A, Polan ML. Hysteroscopic management of intrauterine lesions and intractable uterine bleeding. Obstet Gynecol 1983; 61: 392-97.
Asbestos and the Romans SIR,-Your US Round the World correspondent (July 7, p 41) makes the familiar claim that the health hazards of asbestos were known to the Romans. Neither we nor those whose help we have enlisted have been able to trace any original source. Classical literature contains many references to asbestos and "amiantos", but we have found none to health hazards. That is not surprising, since it is improbable that adverse effects would have been detected two
thousand years ago. Small quantities of chrysotile (white) asbestos appear to have been extracted intermittently in ancient times in north Italy, Corsica, Cyprus, and Arcadia and Euboea in Greece. They were almost certainly obtained from open-cast workings with primitive tools, and modern experience of intensive mining in these regions suggests that attributable illness was unlikely to have been identified. Mining in that era was carried out by slaves and criminals. Plautus’ character Tyndarus, consigned there as a punishment, found nowhere so much like Hell as the stone-quarry: "nulla adaequest Accheruns atque in lapicidinis" (Captivi v: 999). Strabo refers to a mine employing slaves sold cheaply because of their crimes "where the air is said to be destructive of life and scarcely endurable in consequence of the grievous odour issuing from the masses of ore" (Geography xii: 3, 40), but he was referring to ore containing realgar (arsenic disulphide) encountered in a silver mine. The elder Pliny is given credit for referring to the use of respiratory protection against asbestos: "faciem laxis vesicis inligant ne in respirando pemicialem pulverem trahunt" (they tie loose bladders over their faces to prevent the inhalation of pernicious dust as they breathe) (Nat Hist xxxiii; 60: 122), but in this instance the workers were exposed to cinnabar (sulphide of mercury). The story may have arisen from a mistranslation. Plutarch in his life of Sertorius (chap 17) describes the tactical use of a choking dust in the campaign against the Characitanians, in what is now Portugal. He likens the dust to &agr;&sgr;&bgr;∈&sgr;&tgr;&ngr;&ogr;&ngr;, but this word was regularly used in Greek to refer to slaked lime; KfitOtVTO was the word used to describe "the stone which could be combed and woven" (ie,
chrysotile asbestos). 66a Warwick Way, London SW1V 1RZ, UK
KEVIN BROWNE
South Hill, Church Road, Newton Green, Suffolk
ROBERT MURRAY
Leather-bound
ledgers
SIR,-Your peripatetic correspondent (In England Now, July 28) has been enjoying the pursuit of clearing out and browsing among old papers. As professional archivists we were alarmed at the thought that a minute book of a north London fever hospital might have been thrown away. Such stray volumes are still used by medical historians; they are in fact public records and where possible they should be located in a recognised repository. It may well be that such vagrant volumes can be reintegrated into the hospital’s archive even if the hospital itself is now closed. Many hospital records have been placed in local record offices: the records of numerous London hospitals are now in the Greater London Record Office. Other hospitals retain their own records and those of predecessor or associated institutions; and records of the London Fever Hospital, perhaps the hospital concerned in this account, are held at the Royal Free Hospital. At the Wellcome Institute we have a data-base of the information produced by an extensive survey of hospital records conducted in conjunction with the Public Record Office, with the assistance of the King’s Fund Centre. If the "dusty leather-bound ledger" is still available we should be very grateful for a chance to examine it, and if possible, to restore it among its fellows. Contemporary Medical Archives Centre, Wellcome Institute for the History of Medicine, London NW1 2BN, UK
JULIA SHEPPARD LESLEY HALL
Reconstitution of interleukin-2 SIR,-Dr Miles and his colleagues (June 30, p 1602) assume, incorrectly, that West et all may not have used albumin when administering recombinant interleukin-2 (rIL-2). Although not stated specifically in the paper cited by Miles et al, most patients treated by West and colleagues did receive albumin. Thus the extrapolation, based on this incorrect assumption, is invalid; toxicity with the West-type continuous infusion schedule is modified because the daily dose of rIL-2 has been reduced from 126 x 106 for the bolus schedule2 to 30 x 106 U per day for the continuous infusion schedule,’ assuming a standard 70 kg, 1-7 m2 man.
Hysterectomy or what? is the definitive treatment for excessive loss because menstrual drug treatment is at best only temporarily effective. In the UK it is estimated that 40 000 hysterectomies are done yearly for this reason, at a cost of over £ 60 million. The development of an effective, and less hazardous, radical, and costly remedy is therefore highly desirable. Various hysteroscopic techniques for endometrial ablation have lately been advocated,
SIR,-Hysterectomy
including diathermy,’1 cryosurgery ,2 laser3 electromagnetic radiation,4 and resection.5 We have contrasted6 the lack of control over the introduction of surgical techniques compared with the rigorous testing necessary for new drugs. In your July 21 editorial you comment further on this issue, and raise some important questions about the validity and practicality of our prospective, randomised, controlled trial of hysterectomy versus transcervical resection of the endometrium. There should be no disagreement that evaluation of new surgical procedures is necessary, but attitudes towards such techniques and their evaluation are less than objective. For example, you suggest that "if it stands to reason that the new procedure is indeed less risky" then it might not be necessary to go through "the motions of a randomised trial". The earliest ablative procedure was first reported as recently as 19837and all subsequent reports are of small series followed up for a short time. One cannot, therefore, assume that they are accompanied by less risk than hysterectomy until that is properly assessed. That is one aim of our trial. You repeat a frequently expressed pejorative attitude towards randomised, controlled trials when you write of a woman being asked "to sacrifice her womb on the altar of science when a less mutilating alternative is available". The fact of the matter is that hysterectomy is the only proven method to deal effectively with excessive menstrual loss: any new method must therefore be compared against it, and it is unethical to do anything other than compare them scientifically and objectively. The proper area for debate is how best to achieve such comparison for this or any surgical procedures, and full analysis of that requires a wider forum. After due consideration and with the consent of our local ethics committee we have embarked on a randomised, controlled trial to compare hysterectomy with transcervical resection of the endometrium, with the end-points of immediate, short, and long-term risks associated with the procedures, their relative effectiveness, and patient satisfaction. In discussion of our design we considered a third "non-treatment" arm but decided against it because it was not a true new
placebo. At the time of writing over 90 of the required 200 been recruited, a response that we find encouraging.
Department of Obstetrics and Gynaecology, Bristol Maternity Hospital, Bristol BS2 8EG, UK
women
have
GORDON M. STIRRAT NUALA DWYER JAMES BROWNING
1 Vancaille TG Electrocoagulation of the endometrium with the ball-end resectoscope. Obstet Gynecol 1989; 74: 425-27. 2 Davies WAR, Pollard W, Basterfield P. Reduction of menstrual blood loss with endometnal cryosurgery. J Obstet Gynaecol 1985; 6: 117-19. 3. Davies J Hysteroscopic endometrial ablation with the neidymium-YAG laser. Br J Obstet Gynaecol 1989, 96: 928-32. 4 Phipps JH, Lewis BV, Roberts T, et al. Treatment of functional menorrhagia by radiofrequency-induced thermal endometrial ablation. Lancet 1990; 335: 374-76. 5 Magos AL, Baumann R, Tumbull AC Transcervical resection of the endometrium in women with menorrhagia. Br Med J 1989; 298: 1209-12 6 Stirrat GM, Dwyer N, Browning J. Planned trial of transcerervical resection of the endometrium versus hysterectomy. Br J Obstet Gynaecol 1990; 97: 459. 7 De Cherney A, Polan ML. Hysteroscopic management of intrauterine lesions and intractable uterine bleeding. Obstet Gynecol 1983; 61: 392-97.
Asbestos and the Romans SIR,-Your US Round the World correspondent (July 7, p 41) makes the familiar claim that the health hazards of asbestos were known to the Romans. Neither we nor those whose help we have enlisted have been able to trace any original source. Classical literature contains many references to asbestos and "amiantos", but we have found none to health hazards. That is not surprising, since it is improbable that adverse effects would have been detected two
thousand years ago. Small quantities of chrysotile (white) asbestos appear to have been extracted intermittently in ancient times in north Italy, Corsica, Cyprus, and Arcadia and Euboea in Greece. They were almost certainly obtained from open-cast workings with primitive tools, and modern experience of intensive mining in these regions suggests that attributable illness was unlikely to have been identified. Mining in that era was carried out by slaves and criminals. Plautus’ character Tyndarus, consigned there as a punishment, found nowhere so much like Hell as the stone-quarry: "nulla adaequest Accheruns atque in lapicidinis" (Captivi v: 999). Strabo refers to a mine employing slaves sold cheaply because of their crimes "where the air is said to be destructive of life and scarcely endurable in consequence of the grievous odour issuing from the masses of ore" (Geography xii: 3, 40), but he was referring to ore containing realgar (arsenic disulphide) encountered in a silver mine. The elder Pliny is given credit for referring to the use of respiratory protection against asbestos: "faciem laxis vesicis inligant ne in respirando pemicialem pulverem trahunt" (they tie loose bladders over their faces to prevent the inhalation of pernicious dust as they breathe) (Nat Hist xxxiii; 60: 122), but in this instance the workers were exposed to cinnabar (sulphide of mercury). The story may have arisen from a mistranslation. Plutarch in his life of Sertorius (chap 17) describes the tactical use of a choking dust in the campaign against the Characitanians, in what is now Portugal. He likens the dust to &agr;&sgr;&bgr;∈&sgr;&tgr;&ngr;&ogr;&ngr;, but this word was regularly used in Greek to refer to slaked lime; KfitOtVTO was the word used to describe "the stone which could be combed and woven" (ie,
chrysotile asbestos). 66a Warwick Way, London SW1V 1RZ, UK
KEVIN BROWNE
South Hill, Church Road, Newton Green, Suffolk
ROBERT MURRAY
Leather-bound
ledgers
SIR,-Your peripatetic correspondent (In England Now, July 28) has been enjoying the pursuit of clearing out and browsing among old papers. As professional archivists we were alarmed at the thought that a minute book of a north London fever hospital might have been thrown away. Such stray volumes are still used by medical historians; they are in fact public records and where possible they should be located in a recognised repository. It may well be that such vagrant volumes can be reintegrated into the hospital’s archive even if the hospital itself is now closed. Many hospital records have been placed in local record offices: the records of numerous London hospitals are now in the Greater London Record Office. Other hospitals retain their own records and those of predecessor or associated institutions; and records of the London Fever Hospital, perhaps the hospital concerned in this account, are held at the Royal Free Hospital. At the Wellcome Institute we have a data-base of the information produced by an extensive survey of hospital records conducted in conjunction with the Public Record Office, with the assistance of the King’s Fund Centre. If the "dusty leather-bound ledger" is still available we should be very grateful for a chance to examine it, and if possible, to restore it among its fellows. Contemporary Medical Archives Centre, Wellcome Institute for the History of Medicine, London NW1 2BN, UK
JULIA SHEPPARD LESLEY HALL
Reconstitution of interleukin-2 SIR,-Dr Miles and his colleagues (June 30, p 1602) assume, incorrectly, that West et all may not have used albumin when administering recombinant interleukin-2 (rIL-2). Although not stated specifically in the paper cited by Miles et al, most patients treated by West and colleagues did receive albumin. Thus the extrapolation, based on this incorrect assumption, is invalid; toxicity with the West-type continuous infusion schedule is modified because the daily dose of rIL-2 has been reduced from 126 x 106 for the bolus schedule2 to 30 x 106 U per day for the continuous infusion schedule,’ assuming a standard 70 kg, 1-7 m2 man.
