- Email: [email protected]
PROPHYLACTIC PORTACAVAL SHUNT
1247
leagues simply because of the differing ethical viewpoints of the two organisations. Does the M.D.U. take up complaints against doctors brought to their notice by members of the lay public ? If not, why does it act only when the complaints are made by doctors ? As Dr. Addison knows, I resigned my membership of the M.D.U. over this issue, so I cannot accept his offer to complain to the M.D.U. Council, but I hope that he will accept this letter as doing so from an ex-member. Kingston Hospital, Wolverton Avenue, Kingston upon Thames, PETER DIGGORY. Surrey. SIR,-The Secretary of the Medical Defence Union only half a clause. In full the objective of the Company is stated as To promote honourable practice, quotes
"
and to suppress or prosecute unqualified practitioners." Clearly this object of the Company is to enable it to deal with charlatans and not with fully qualified honourable practitioners such as Dr. Deys. I have directed a letter of censure to the Council of the Medical Defence Union.
view would have made
a finding of guilty by the Discia Committee conclusion. Finding that the foregone plinary offender was a member of the M.D.U. and with the agreement of my correspondent, I submitted the evidence to one of Dr. Addison’s colleagues who communicated with their member. Within a week or two the offending advertisements had been removed, an apology and offer of amends proffered and accepted, and harmony restored. But what if we had failed in our joint endeavour ? The B.M.A. ethical machinery might have helped, but conceivably I might have had to advise a complaint to the G.M.C. Had I done so-and I cannot recall ever personally giving such advice-then the limit of the Society’s involvement would have been the provision of legal assistance. The member, however highly respected, would not have been permitted to shield his identity behind my signature. Had the M.D.U. dealt with the complaint regarding Dr. Deys in similar manner, would perhaps the profession have been better served ?
50 Hallam Street, London W1N 6DE.
J. LEAHY TAYLOR, Secretary, Medical Protection Society.
Great
Oakley, Harwich,
BENEDICT HOSKYNS.
Essex.
SIR,-It seems very doubtful whether the curbing of unprofessional activity by doctors is a proper purpose of a defence society; this should surely be one of the duties of the General Medical Council and if that body is not entitled to initiate proceedings, perhaps that could be looked into by the public inquiry. But what is quite monstrous is the statement by the Secretary of the Medical Defence Union, to which I belong, that in the promotion of honourable practice " his Union "
does report to the G.M.C. the conduct of certain doctors who belong to other defence organisations but would not do so in the case of their own members. Surely, Sir, he should either report any doctor of whatever defence organisation or none.
2
Knighton Grange Road, Leicester LE2 2LE.
PAUL HICKINBOTHAM.
SIR,- The position of the Medical Protection Society in respect of its relationship with the General Medical Council was mis-stated in last week’s correspondence, and I write to put the record straight. May I at the same time suggest that in any further matters affecting the Society your readers might prefer to have first-hand information ? So far as the case of Dr. Deys was concerned, the position of the M.P.S. was simply that we successfully defended her against the complaint brought by the M.D.U. Mr. Diggory asks " Is it not time that both parties (the M.P.S. and the M.D.U.) stated their position on this issue ? The fact is that we have stated our position to any member who has asked. There is no mystery whatever: we do not now and have not for many years seen our role as including the laying of complaints before the G.M.C. The statement to the contrary by my friend, Dr. Addison, is therefore incorrect. Lest your readers might assume that the difference in policy results from the M.D.U. members all being " highly respected " and those of the M.P.S. being " worthy of inquiry by the Disciplinary Committee " it may help if I refer to a case of a year or two ago. A member of the M.P.S. practising in a two-doctor village wrote complaining of blatant advertising by his colleague, and provided me with evidence which in my "
PROPHYLACTIC PORTACAVAL SHUNT SiR,—Your editorialgave an elegant discussion of the problem of operative prevention of exsanguinating haemorrhage from varices. I should like to make two observations. You state: " Operations must be devised which will lower portal blood-pressure but maintain perfusion of the liver with blood ". An operation has been devised by Warren and his associates which drains the varices through the spleen into the renal vein (distal splenorenal shunt).II In order to prevent hxmorrhage from varices, lowering portal pressure is not necessary. The unique feature of the Warren operation is that it interferes little with portal blood-flow in most patients. To accomplish this, two procedures were combined: one is the anastomosis of the splenic end of the splenic vein to the renal vein, and the other one is the gastric devascularisation and portalazygos disconnection to prevent either the overloading of the drainage system designed for decompression of varices and to prevent the syphoning off the portal blood-flow away from the liver into the new low-pressure reservoir. The purpose of operation on the portal system is not to deprive the liver of portal venous flow but to prevent bleeding from varices by decompressing only the varices themselves. Other operations have been based on the principle introduced in the surgical thinking of the mid1940s by Whipple, Blakemore, and their associates. 3.-1 The Warren operation is the first major effort to provide for the prevention of variceal haemorrhage without causing a biologically meaningful decrease of portal venous flow to the liver. This is precisely the type of procedure that
asking for, and it is important to point operation is available, it has been used, and the initial excessive mortality-rate had been overcome. The operation has prevented bleeding. Now a controlled your editorial out that such
was an
clinical trial is under way to compare the anticipated lower incidence of postoperative encephalopathy after the Warren operation with that of the classic portacaval shunts by randomly assigning selected patients into the two operative
categories. " nature The second point concerns the " prophylactic of the operations. You mention " four prospective controlled trials of prophylactic portacaval shunting " in patients with oesophageal varices who had not bled. You did not
1. 2. 3. 4.
Lancet, 1972, i, 999. Warren, W. D., Zeppa, R., Fomon, J. J. Ann. Surg. 1967, 166, 437,
Whipple, A. O. Bull. N. Y. Acad. Med. 1946, 22, Blakemore, A. H. ibid. p. 254.
251.
1248
point out that, with the exception of the few emergency operations, the vast majority of these procedures are prophylactic shunts. They are done to prevent bleeding in the future. Just because they are done in patients who have bled in the past, that does not change the prophylactic Since you stressed the lack of nature of the operation. clinical usefulness of prophylactic shunts, it seems logical suspect that the clinical value of prophylactic shunts is just as doubtful when the same operation is performed for the same purpose in the same type of patients who had bled weeks or months previously. It is essential that a properly controlled prospective clinical trial be made to evaluate the efficacy and clinical usefulness of the " prophylactic " shunt operations in patients who did bleed in the past. However, this type of prospective controlled clinical trial cannot be performed at this time, because, to date, patient selection for prophylactic surgery was based on arbitrary criteria arrived at by empirical " liver-function tests " which are means and dependent on to whether or not the patient is likely to helpful predict survive the operation. There are two major considerations to be resolved before a prospective trial on the clinical value of shunt operations for the prevention of variceal bleeding can be evaluated, whether these patients did or did not bleed previously: (1) A clinically applicable method must be developed which can predict with a high degree of reliability whether or not a patient can tolerate a shunt without encephalopathy
operative thrombosis
are
that the facts set
hope carefully studied. With
perhaps even more important. I by Mr. Denis Burkitt will be
out
over 5 million cases of varicose veins in this country and over 7 million people on habitual purgatives, there is room for this study.
Redmarley, Sandringham Road, Catisfield, Fareham, Hampshire.
T. L. CLEAVE.
to
developing. (2) Whether the distal splenorenal shunt is indeed less likely to produce postoperative encephalopathy than the classic " types of shunt operations; all these have in common is the diversion of portal blood from the liver, whether or not they ligate the portal vein or create a lowpressure drain in the portal system. Once these questions can be answered, then proper stratification and randomisation of operations and patients can be performed and valid conclusions can be reached regarding the clinical usefulness of the different types of procedures in various abnormalities in the portal system. It is hoped that within the next two years adequate "
data will be accumulated in these two problems.
our
Department of Medicine, Emory University School of Medicine, Atlanta, Georgia 30303, U.S.A.
institutions
to
resolve
JOHN T. GALAMBOS.
VARICOSE VEINS
SIR,-With regard to the articles on the treatment of varicose veins (Dec. 2, p. 1188 and p. 1191), I could not help being struck by the lack of reference to the removal of
a cause.
Since varicose veins
are so common
in
our
population, who eat a mass of refined carbohydrate and have a prolonged intestinal transit-time, but are almost unknown 1-3 in those populations subsisting on unrefined carbohydrates and having a halved intestinal transit-time in consequence, is it not vital at least to consider the removal of a colonic-pressure cause on the external iliac veins at the
pelvic brim ? (It is to be noted that populations having no varicose veins acquire them as soon as they move on to a refined Westernised diet, thus disproving a hereditary cause.) The halving of the intestinal transit-time can be secured very easily by the taking of unprocessed bran at a cost of only a few pence a month and is in full swing in at least one British hospital.44 The implications in post1. 2. 3. 4.
Cleave, T. L., Campbell, G. D. C., Painter, N. S. Diabetes, Coronary Thrombosis and the Saccharine Disease. Bristol, 1969. Burkitt, D. B. Br. med. J. 1972, ii, 556. Burkitt, D. B. ibid. 1972 iv, 231. Latto, C. ibid. 1972, iii, 705.
" ANDROGEN DYSGENESIS ": A PREDISPOSING FACTOR IN SCHIZOPHRENIA ? SIR,—This theory could be considered as a revival and revision of several lines of thinking of the past. There is, to me, a clear contrast between leadership and schizothymia: schizoids may be strong in imagination, but generally they are poor in organising and influencing others; and leadership is a quality of masculinity rather than of femininity. This observation led me to formulate a theory, only as one of the logical possibilities. A large body of evidence illustrates a positive correlation between constitutional androgenicity or testosterone output and dominant and/or aggressive behaviour 1-3 as well as automatised cognition,4 and between passivity, neuroticism, or sociopathic behaviour and hypoandrogenicity.5 Androgens have anxsthetic, hypnotic, or tranquillising properties.6 Their anabolic property may be important in the early development and organisation of the central nervous system,! and possibly, by promoting protein and R.N.A. synthesis, in learning and memory.8 Indirect evidence shows that androgens can modify monoamine-oxidase (M.A.O.) activity in certain regions of the brain.44 My unpublished findings indicate that two weeks after castration of male rats, M.A.O. activity in the temporal cortex is much increased, but no significant effect is noted in the hypothalamus. The mainstay of my argument is that slight differences in the three-dimensional configuration of steroids,9 including the androgens" could greatly alter their physiological properties. The extra-neuronal observations (see tables 10 describing the widely different anabolic action of over 600 androgen-like steroids, mostly synthetic, on the ventral prostate, seminal vesicles, and levator ani) could be obtained at the neuronal level also; autoradiographic studies with other steroids 11-13 seem to support this contention. A change in urinary androsterone/etiocholanolone ratio has been noted in some male homosexuals.14 Dehydroepiandrosterone was shown to have more psychic
influence, promoting aggression, self-confidence, and
a
It could sociable attitude than testosterone.15 therefore be argued that if the C.N.S. regions are mapped to determine the uptake and/or influence of various androgen-like steroids, some of them, by virtue of their stereochemical affinity to the receptor or effector macromolecules, more
1.
Lunde,
D.
T., Hamburg, D.
A. Recent
Prog. Horm. Res. 1972, 28,
627. 2.
3. 4.
5. 6. 7. 8. 9. 10. 11. 12.
13. 14. 15.
Rose, R. M. Annual Meeting of the American Psychosomatic Society, Boston, April 15, 1972. Andrew, R. J., Rogers, L. J. Nature, 1972, 237, 343. Klaiber, E. L., Broverman, D. M., Kobayashi, Y. Psychopharmacologia, 1967, 11, 320. Wakeling, A. Psychol. Med. 1972, 2, 139. Overbeek, C. A., Bonta, I. L. in Hormonal Steroids (edited by L. Martini and A. Pecile); p. 493. New York, 1964. Glassman, E. Ann. Rev. Biochem. 1969, 38, 605. Hydén, H., Lange, P. W. Brain Res. 1970, 22, 423. Ganong, W. F. Medical Physiology; p. 270. Los Altos, 1971. Vida, J. A. Androgens and Anabolic Agents. New York, 1969. Stumpf, W. E. Fedn Proc. 1971, 30, 309. McEwen, B. S., Pfaff, D. W., Zigmond, R. E. Brain Res. 1970, 21, 1, 17, 29. Tuohimaa, P., Niemi, M. Acta endocr., Copenh. 1972, 71, 37, 45. Margolese, M. S. Horm. Behav. 1970, 1, 151. Sands, D. E. J. ment. Sci. 1954, 100, 211.
leagues simply because of the differing ethical viewpoints of the two organisations. Does the M.D.U. take up complaints against doctors brought to their notice by members of the lay public ? If not, why does it act only when the complaints are made by doctors ? As Dr. Addison knows, I resigned my membership of the M.D.U. over this issue, so I cannot accept his offer to complain to the M.D.U. Council, but I hope that he will accept this letter as doing so from an ex-member. Kingston Hospital, Wolverton Avenue, Kingston upon Thames, PETER DIGGORY. Surrey. SIR,-The Secretary of the Medical Defence Union only half a clause. In full the objective of the Company is stated as To promote honourable practice, quotes
"
and to suppress or prosecute unqualified practitioners." Clearly this object of the Company is to enable it to deal with charlatans and not with fully qualified honourable practitioners such as Dr. Deys. I have directed a letter of censure to the Council of the Medical Defence Union.
view would have made
a finding of guilty by the Discia Committee conclusion. Finding that the foregone plinary offender was a member of the M.D.U. and with the agreement of my correspondent, I submitted the evidence to one of Dr. Addison’s colleagues who communicated with their member. Within a week or two the offending advertisements had been removed, an apology and offer of amends proffered and accepted, and harmony restored. But what if we had failed in our joint endeavour ? The B.M.A. ethical machinery might have helped, but conceivably I might have had to advise a complaint to the G.M.C. Had I done so-and I cannot recall ever personally giving such advice-then the limit of the Society’s involvement would have been the provision of legal assistance. The member, however highly respected, would not have been permitted to shield his identity behind my signature. Had the M.D.U. dealt with the complaint regarding Dr. Deys in similar manner, would perhaps the profession have been better served ?
50 Hallam Street, London W1N 6DE.
J. LEAHY TAYLOR, Secretary, Medical Protection Society.
Great
Oakley, Harwich,
BENEDICT HOSKYNS.
Essex.
SIR,-It seems very doubtful whether the curbing of unprofessional activity by doctors is a proper purpose of a defence society; this should surely be one of the duties of the General Medical Council and if that body is not entitled to initiate proceedings, perhaps that could be looked into by the public inquiry. But what is quite monstrous is the statement by the Secretary of the Medical Defence Union, to which I belong, that in the promotion of honourable practice " his Union "
does report to the G.M.C. the conduct of certain doctors who belong to other defence organisations but would not do so in the case of their own members. Surely, Sir, he should either report any doctor of whatever defence organisation or none.
2
Knighton Grange Road, Leicester LE2 2LE.
PAUL HICKINBOTHAM.
SIR,- The position of the Medical Protection Society in respect of its relationship with the General Medical Council was mis-stated in last week’s correspondence, and I write to put the record straight. May I at the same time suggest that in any further matters affecting the Society your readers might prefer to have first-hand information ? So far as the case of Dr. Deys was concerned, the position of the M.P.S. was simply that we successfully defended her against the complaint brought by the M.D.U. Mr. Diggory asks " Is it not time that both parties (the M.P.S. and the M.D.U.) stated their position on this issue ? The fact is that we have stated our position to any member who has asked. There is no mystery whatever: we do not now and have not for many years seen our role as including the laying of complaints before the G.M.C. The statement to the contrary by my friend, Dr. Addison, is therefore incorrect. Lest your readers might assume that the difference in policy results from the M.D.U. members all being " highly respected " and those of the M.P.S. being " worthy of inquiry by the Disciplinary Committee " it may help if I refer to a case of a year or two ago. A member of the M.P.S. practising in a two-doctor village wrote complaining of blatant advertising by his colleague, and provided me with evidence which in my "
PROPHYLACTIC PORTACAVAL SHUNT SiR,—Your editorialgave an elegant discussion of the problem of operative prevention of exsanguinating haemorrhage from varices. I should like to make two observations. You state: " Operations must be devised which will lower portal blood-pressure but maintain perfusion of the liver with blood ". An operation has been devised by Warren and his associates which drains the varices through the spleen into the renal vein (distal splenorenal shunt).II In order to prevent hxmorrhage from varices, lowering portal pressure is not necessary. The unique feature of the Warren operation is that it interferes little with portal blood-flow in most patients. To accomplish this, two procedures were combined: one is the anastomosis of the splenic end of the splenic vein to the renal vein, and the other one is the gastric devascularisation and portalazygos disconnection to prevent either the overloading of the drainage system designed for decompression of varices and to prevent the syphoning off the portal blood-flow away from the liver into the new low-pressure reservoir. The purpose of operation on the portal system is not to deprive the liver of portal venous flow but to prevent bleeding from varices by decompressing only the varices themselves. Other operations have been based on the principle introduced in the surgical thinking of the mid1940s by Whipple, Blakemore, and their associates. 3.-1 The Warren operation is the first major effort to provide for the prevention of variceal haemorrhage without causing a biologically meaningful decrease of portal venous flow to the liver. This is precisely the type of procedure that
asking for, and it is important to point operation is available, it has been used, and the initial excessive mortality-rate had been overcome. The operation has prevented bleeding. Now a controlled your editorial out that such
was an
clinical trial is under way to compare the anticipated lower incidence of postoperative encephalopathy after the Warren operation with that of the classic portacaval shunts by randomly assigning selected patients into the two operative
categories. " nature The second point concerns the " prophylactic of the operations. You mention " four prospective controlled trials of prophylactic portacaval shunting " in patients with oesophageal varices who had not bled. You did not
1. 2. 3. 4.
Lancet, 1972, i, 999. Warren, W. D., Zeppa, R., Fomon, J. J. Ann. Surg. 1967, 166, 437,
Whipple, A. O. Bull. N. Y. Acad. Med. 1946, 22, Blakemore, A. H. ibid. p. 254.
251.
1248
point out that, with the exception of the few emergency operations, the vast majority of these procedures are prophylactic shunts. They are done to prevent bleeding in the future. Just because they are done in patients who have bled in the past, that does not change the prophylactic Since you stressed the lack of nature of the operation. clinical usefulness of prophylactic shunts, it seems logical suspect that the clinical value of prophylactic shunts is just as doubtful when the same operation is performed for the same purpose in the same type of patients who had bled weeks or months previously. It is essential that a properly controlled prospective clinical trial be made to evaluate the efficacy and clinical usefulness of the " prophylactic " shunt operations in patients who did bleed in the past. However, this type of prospective controlled clinical trial cannot be performed at this time, because, to date, patient selection for prophylactic surgery was based on arbitrary criteria arrived at by empirical " liver-function tests " which are means and dependent on to whether or not the patient is likely to helpful predict survive the operation. There are two major considerations to be resolved before a prospective trial on the clinical value of shunt operations for the prevention of variceal bleeding can be evaluated, whether these patients did or did not bleed previously: (1) A clinically applicable method must be developed which can predict with a high degree of reliability whether or not a patient can tolerate a shunt without encephalopathy
operative thrombosis
are
that the facts set
hope carefully studied. With
perhaps even more important. I by Mr. Denis Burkitt will be
out
over 5 million cases of varicose veins in this country and over 7 million people on habitual purgatives, there is room for this study.
Redmarley, Sandringham Road, Catisfield, Fareham, Hampshire.
T. L. CLEAVE.
to
developing. (2) Whether the distal splenorenal shunt is indeed less likely to produce postoperative encephalopathy than the classic " types of shunt operations; all these have in common is the diversion of portal blood from the liver, whether or not they ligate the portal vein or create a lowpressure drain in the portal system. Once these questions can be answered, then proper stratification and randomisation of operations and patients can be performed and valid conclusions can be reached regarding the clinical usefulness of the different types of procedures in various abnormalities in the portal system. It is hoped that within the next two years adequate "
data will be accumulated in these two problems.
our
Department of Medicine, Emory University School of Medicine, Atlanta, Georgia 30303, U.S.A.
institutions
to
resolve
JOHN T. GALAMBOS.
VARICOSE VEINS
SIR,-With regard to the articles on the treatment of varicose veins (Dec. 2, p. 1188 and p. 1191), I could not help being struck by the lack of reference to the removal of
a cause.
Since varicose veins
are so common
in
our
population, who eat a mass of refined carbohydrate and have a prolonged intestinal transit-time, but are almost unknown 1-3 in those populations subsisting on unrefined carbohydrates and having a halved intestinal transit-time in consequence, is it not vital at least to consider the removal of a colonic-pressure cause on the external iliac veins at the
pelvic brim ? (It is to be noted that populations having no varicose veins acquire them as soon as they move on to a refined Westernised diet, thus disproving a hereditary cause.) The halving of the intestinal transit-time can be secured very easily by the taking of unprocessed bran at a cost of only a few pence a month and is in full swing in at least one British hospital.44 The implications in post1. 2. 3. 4.
Cleave, T. L., Campbell, G. D. C., Painter, N. S. Diabetes, Coronary Thrombosis and the Saccharine Disease. Bristol, 1969. Burkitt, D. B. Br. med. J. 1972, ii, 556. Burkitt, D. B. ibid. 1972 iv, 231. Latto, C. ibid. 1972, iii, 705.
" ANDROGEN DYSGENESIS ": A PREDISPOSING FACTOR IN SCHIZOPHRENIA ? SIR,—This theory could be considered as a revival and revision of several lines of thinking of the past. There is, to me, a clear contrast between leadership and schizothymia: schizoids may be strong in imagination, but generally they are poor in organising and influencing others; and leadership is a quality of masculinity rather than of femininity. This observation led me to formulate a theory, only as one of the logical possibilities. A large body of evidence illustrates a positive correlation between constitutional androgenicity or testosterone output and dominant and/or aggressive behaviour 1-3 as well as automatised cognition,4 and between passivity, neuroticism, or sociopathic behaviour and hypoandrogenicity.5 Androgens have anxsthetic, hypnotic, or tranquillising properties.6 Their anabolic property may be important in the early development and organisation of the central nervous system,! and possibly, by promoting protein and R.N.A. synthesis, in learning and memory.8 Indirect evidence shows that androgens can modify monoamine-oxidase (M.A.O.) activity in certain regions of the brain.44 My unpublished findings indicate that two weeks after castration of male rats, M.A.O. activity in the temporal cortex is much increased, but no significant effect is noted in the hypothalamus. The mainstay of my argument is that slight differences in the three-dimensional configuration of steroids,9 including the androgens" could greatly alter their physiological properties. The extra-neuronal observations (see tables 10 describing the widely different anabolic action of over 600 androgen-like steroids, mostly synthetic, on the ventral prostate, seminal vesicles, and levator ani) could be obtained at the neuronal level also; autoradiographic studies with other steroids 11-13 seem to support this contention. A change in urinary androsterone/etiocholanolone ratio has been noted in some male homosexuals.14 Dehydroepiandrosterone was shown to have more psychic
influence, promoting aggression, self-confidence, and
a
It could sociable attitude than testosterone.15 therefore be argued that if the C.N.S. regions are mapped to determine the uptake and/or influence of various androgen-like steroids, some of them, by virtue of their stereochemical affinity to the receptor or effector macromolecules, more
1.
Lunde,
D.
T., Hamburg, D.
A. Recent
Prog. Horm. Res. 1972, 28,
627. 2.
3. 4.
5. 6. 7. 8. 9. 10. 11. 12.
13. 14. 15.
Rose, R. M. Annual Meeting of the American Psychosomatic Society, Boston, April 15, 1972. Andrew, R. J., Rogers, L. J. Nature, 1972, 237, 343. Klaiber, E. L., Broverman, D. M., Kobayashi, Y. Psychopharmacologia, 1967, 11, 320. Wakeling, A. Psychol. Med. 1972, 2, 139. Overbeek, C. A., Bonta, I. L. in Hormonal Steroids (edited by L. Martini and A. Pecile); p. 493. New York, 1964. Glassman, E. Ann. Rev. Biochem. 1969, 38, 605. Hydén, H., Lange, P. W. Brain Res. 1970, 22, 423. Ganong, W. F. Medical Physiology; p. 270. Los Altos, 1971. Vida, J. A. Androgens and Anabolic Agents. New York, 1969. Stumpf, W. E. Fedn Proc. 1971, 30, 309. McEwen, B. S., Pfaff, D. W., Zigmond, R. E. Brain Res. 1970, 21, 1, 17, 29. Tuohimaa, P., Niemi, M. Acta endocr., Copenh. 1972, 71, 37, 45. Margolese, M. S. Horm. Behav. 1970, 1, 151. Sands, D. E. J. ment. Sci. 1954, 100, 211.