- Email: [email protected]
A SELECTIVE PORTACAVAL SHUNT
51
shown, for instance, in
a woman after total pancreatectomy a nil rise in virtually serum-lipid becoming a normal rise after medication with pancreatic enzymes. The new test is certainly more reliable, and easier and quicker, with the result the same day instead of after a 5 or 6 day collection of fxces, but it is not likely to be more sensitive than fxcal-fat mp5iQiiri-nit-nt
Nuffield Department of Clinical Biochemistry, Nuffield Department of Surgery, Radcliffe Infirmary,
W. A. F. PENFOLD. W. M. KEYNES.
Medical Professorial Unit St. Bartholomew’s Hospital, London E.C.1.
P. W. P. BUTLER G. M. BESSER.
A PREREGISTRATION PROBLEM
Oxford.
STEATORRHŒA AND PLASMA-ALKALINE-PHOSPHATASE a genetic explanation for the steatorplasma-alkaline-phosphatase of intestinal origin reported by Professor Dent and his colleagues (June 22, p. 1333). Intestinal lymphoma seems to be prevalent in nonAshkenazi Jews and Arabs in Israel.1-3 In such patients and their relatives, and in some patients with malabsorption alone, there is a high incidence of serum-alkaline-phosphatase intestinal isoenzyme; and in a few the serum-values are strikingly raised 11.4 The patient studied by Professor Dent and his colleagues was a Pakistani; perhaps patients of MiddleEastern or Asian origin with " idiopathic steatorrhoea should have their plasma-alkaline-phosphatase isoenzymes measured routinely to see whether they have a specific, perhaps genetically
SiR,—There
within these limits in each of our patients after successful treatment of their depression, when studied in the same environment, indicates that the pre-treatment abnormality is associated with the depressive illness rather than the environment.
may be
rhcea and raised
SIR,-Many of us share Professor Brooke’s concern in his letter last week (p. 1425) about the problems of the married preregistration house-officer and her child. In my Group we avoid the problem of asking the G.M.C. to amend their regulations. We provide married quarters for preregistration doctors whenever possible. The ingenuity, intelligence, and determination of the incumbents does the rest. High Moor, Wrightington, nr. Wigan, Lancs.
R. M. FORRESTER.
A SELECTIVE PORTACAVAL SHUNT
"
"
determined, malabsorotion svndrome. Prince of Wales’s General Hospital London N.15.
D. M. KRIKLER.
PITUITARY-ADRENAL FUNCTION IN DEPRESSION
SIR,-It is difficult
accept that the diurnal rhythm of levels was normal in our severely
to
plasma-hydrocortisone depressed patients (June 8, p. 1234) as suggested by Dr. Carrol and his colleagues (June 22, p. 1373). It is our experience, in agreement with Mattingly,5 Ross et al.,6 and others, that a fundamental feature of a normal diurnal rhythm is a midnight hydrocortisone level of less than 7 {jLg. per 100 ml. The diurnal rhythm in patients with Cushing’s syndrome is widely accepted as being " abnormal ". In this condition the highest hydrocortisone level may be found at midnight, as in our depressed patient 3, but not infrequently it is lower then than at 9 A.M. while undoubtedly still being elevated for this time of day. 6The midnight levels in our depressed patients 1
and 2 ranged between 13 and 20 tg. per 100 ml., and although lower than at 9 A.M. must be considered abnormal. Deviations from normality cannot be recognised by a comparison between 2 abnormal groups of patients. While it is of interest to compare depressed with other psychiatrically ill patients, the latter group cannot be used to define the normal range, as Dr. Carrol and his colleagues suggest. The lack of normal dexamethasone suppression reported in 3 of their non-depressed but psychiatrically ill patients supports the view that such patients cannot constitute a valid normal control population. Alternatively these results could be due to the reported inherent unreliability of the single-dose dexamethasone test employed.88 We have confirmed the published normal ranges for the diurnal rhythm of plasma-hydrocortisone levels obtained from convalescent non-stressed hospital patients.69 The return of the diurnal rhythm to 1. 2. 3. 4. 5. 6. 7. 8.
9.
Ramot, B., Shahin, N., Bubis, J. J. Israel. J. med. Sci. 1965, 1, 221. Eidelman, S., Parkins, R. A., Rubin, C. E. Medicine, Baltimore, 1966, 45, 111. Clinicopathological Conference. Israel J. med. Sci., 1968, 4, 164. Ramot, B., Streifler, C. Lancet, 1966, ii, 587. Mattingly, D. Proc. R. Soc. Med. 1963, 56, 717. Ross, E. J., Marshall-Jones, P., Friedman, M. Q. Jl. Med. 1966, 35, 149. Cope, C. L. Br. med. J. 1966, ii, 847. Connolly, C. K., Gore, M. B. R., Stanley, N., Wills, M. R. Br. med. J. 1968, ii, 665. Mattingly, D. in Recent Advances in Medicine (edited by D. N. Baron, N. Compston, and A. M. Dawson); p. 125. London, 1968.
SIR,-Although the standard portacaval shunt controls haemorrhage from oesophageal varices, there are several postoperative complications, such as Eck’s syndrome or hepatic failure, and the operation has not improved the survival-rate. In Japan, postnecrotic cirrhosis of the liver seems to be more common, and the direct portacaval shunt is contraindicated. Non-shunting surgical procedures have proved superior with regard to hepatic function, but are accompanied by nutritional imbalance and often recurrent bleeding. A new operative procedure has been developed in this department in which selective shunting is accomplished through the left gastric vein to the inferior vena cava (see accompanying figure). The rationale of the procedure is to decompress the area of oesophageal varices while maintaining a high portal pressure and providing adequate portal flow to the liver.
Selective shunt through left gastric vein
to
inferior
vena cava.
The dilated and engorged left gastric vein is dissected and severed as near as possible to the portal trunk, and the gastric stump is shunted to the inferior vena cava using an autogenous vein-graft taken from the great saphenous vein. In some situations, according to the anatomical variation, the left gastric vein is shunted to the right spermatic (or ovarian) vein directly, or to the left adrenal or renal vein with a vein-graft. The wall of the left gastric vein is often easily injured owing to the increased portal pressure and the resultant fibrosis, but use of our mechanical suturing instrument provides a simple and secure technique for the anastomosis, with a satisfactory result. In fact, no case has shown difficulty with this surgical
procedure.
52 Fifteen patients have been operated upon. Their liver function was impaired and the usual shunt operation was not indicated. All except two, in whom ascites and a hxmorrhagic were noted postoperatively owing to severe hepatic have made an uneventful postoperative recovery. damage, The mean left gastric venous pressure before operation (295 mm. water) decreased to 201 mm. water after the shunt, whereas the portal pressure was not changed by this procedure in most cases. Mean shunting blood-flow, measured by electromagnetic flow-meter, recorded 45-200 ml. per minute. (Esophageal varices, which had been noted preoperatively in all cases, have disappeared or have strikingly improved, and there has been no recurrent bleeding in any case during 10 months’ observation after the operation. Liver function and ammonium metabolism were only slightly influenced, suggesting that this procedure could be used with little risk even in patients with severe hepatic damage.
tendency
Increase in size and increase in basophilia of the cytoplasm was also noted in the lymphocytes of patients with aplastic anaemia treated with phytohxmagglutinin.3 We note also that unusual primitive, plasma-like cells were found in the lymphoid tissue and peripheral blood of small animals with E.A.E.4 To our knowledge such cells have not been described previously in human demyelinating diseases. Since E.A.E. is an example of autohypersensitivity it might not be imprudent to suggest that such cells might be observed in other autohypersensitivity diseases, and it would be of interest to know if they could be found in the peripheral blood of patients with multiple sclerosis. A complete account of the investigations on these patients and animals is in preparation for publication. Boston University Medical School, PETER O. BEHAN Veterans Administration Hospital,
Boston,
Although more experience is needed to make a definite evaluation, our new procedure is believed to widen the indications for the surgical treatment of oesophageal varices due
nortal hvnertension. Department of Surgery, Kyushu University Medical School, Fukuoka, Japan.
ORF
SiR,-Since there
to
are more
A NEW CELL IN DEMYELINATING DISEASE ?
SIR,-We report here an observation we have made on the peripheral blood of two patients, one with acute disseminated encephalomyelitis (A.D.E.M.), the other with acute haemorrhagic leucoencephalitis (A.H.L.E.), and on nine rhesus monkeys in which acute allergic encephalomyelitis (E.A.E.) was induced. One of the patients was thought clinically to have had a cerebral tumour and the diagnosis of A.H.L.E. was confirmed microscopically. E.A.E. was induced by a single injection of 500 µg. of a basic protein fraction of monkey centralnervous-system myelin (prepared and supplied by Dr. M. Kies of the National Institute of Mental Health) in Freund’s adjuvant containing killed mycobacteria. This was given intradermally into the left foot-pad of each animal and was followed after a variable period (average duration 16 days) by the clinical appearance of E.A.E. The diagnosis was confirmed by microscopy in each monkey. The abnormal cells (vide infra) were observed in the peripheral blood of the monkeys 4 days before the clinical onset of symptoms and were present when they were killed 4 days after onset of symptoms. In the patients, the cells were first noted in the one with A.H.L.E. in the early course of the disease, and were still present a month later when the patient was still very ill. In the second very small number of abnormal cells were still present two years after the onset of the disease. The cells have the appearance of abnormal lymphocytes. These vary from very large primitive cells up to 40 [L in diameter with large
sheep than men in Northumber-
bound to see the occasional case f orf. Whether our Newcastle dermatologists will see them is more doubtful, since the average country practitioner has more sense than to send a self-healing pustule 30 miles to hospital from a farm 2 miles from the nearest bus-stop. Surely a disease described as pustular dermatitis will at least be characterised by pustules rather than by weeping maculopapules, and the four cases that I have seen or imagined myself to have seen (electronically they might have been something else) were more in the nature of septic blisters without any fluid content, but with a thin layer of necrotic skin, easily cut away to reveal dark velvety granulations which I have seen described as characteristic (reference unfortunately not to hand). These cases cleared rapidly under a simple non-adherent dressing and in spite of intramuscular penicillin. Incidentally one was the wife of an affected shepherd who practically lived with his prize sheep-she had not been in direct contact with the sheep, and I have always regretted that I did not note the incubation period of this apparent human-
land, general practitioners KIYOSHI INOKUCHI.
JACQUES B. LAMARCHE.
Massachusetts 02130.
are
tn-human infection-
Amble, by Morpeth,
R. P. ROBERTSON.
Northumberland. 3. 4.
Humble, J. G. Lancet, 1964, i, 345. Dowling, P., Cook, S. Neurology, Minneap. 1968, 18, 295.
Diary of the Week
case a
nearly
nuclei containing nucleoli, and intensely basophilic cytoplasm with conspicuous small vacuoles, to atypical lymphocytes which vary from 12 fL to 20 [L in diameter, and have basophilic cytoplasm and nuclear chromatin of plasmacytoid type. In view of the current hypothesis that E.A.E., A.H.L.E., and A.D.E.M. are allergic in xtiology, and that the demyelination is caused by cellular mechanism of delayed sensitivity, such cells may be the immunoblasts involved in this reaction. One of us (P. 0. B.) has shown blastic transformation in short-term cultures of lymphocytes from both patients and from the monkeys, the specific mitogen being human and monkey encephalitogenic protein. Barker et al. described peripheralblood plasmacytosis with large " plasmacytoid lymphocytes " in the peripheral blood undergoing mitosis in patients after systemic exposure to Phytolacca americana (pokeweed).
basophilic
1. Kies, M. W., Murphy, J. B., Alvord, E. C., Jr., in Chemical Pathology of the Nervous System (edited by Folch-Pi); p. 197. Oxford, 1961. 2. Barker, B. E., Farnes, P., LaMarche, P. H. Pediatrics, Springfield, 1966, 38, 490.
JULY 7
TO
13
Tuesday, 9th ROYAL COLLEGE OF SURGEONS W.C.2 5 P.M. Mr. E. R. Owen:
OF
ENGLAND, Lincoln’s Inn Fields, London
Preventing the Rejection of Transplanted Organs. (Hunterian lecture.) ROYAL POSTGRADUATE MEDICAL SCHOOL, Ducane Road, London W.12 4 P.M. Mr. G. C. Knight: Stereotactic Tractotomy in Mental Illness.
Wednesday, 10th ROYAL COLLEGE OF SURGEONS OF ENGLAND 3 P.M. Prof. David Slome: Experimental Surgical Research at Downe. (Bernhard Baron lecture.) INSTITUTE OF CHILD HEALTH, 30 Guilford Street, London W.C.1 5.30 P.M. Dr. R. W. E. Watts: Cystinuria. INSTITUTE OF ORTHOPEDICS, 234 Great Portland Street, London W.1 8.15 P.M. Mr. P. H. Newman: Lumbosacral Subluxation and the Adolescent Growth Period. ROYAL FREE HOSPITAL, Gray’s Inn Road, London W.C.1 5.15 P.M. Dr. L. E. Siltzbach (New York): Pulmonary Aspergillosis.
Thursday, llth ROYAL POSTGRADUATE MEDICAL SCHOOL 4 P.M. Prof. H. H. Bentall: Heart-valve
Replacement.
Friday, 12th ROYAL POSTGRADUATE MEDICAL SCHOOL 10.15 A.M. Mr. J. C. Mustarde: Reconstruction Around the Orbit.
shown, for instance, in
a woman after total pancreatectomy a nil rise in virtually serum-lipid becoming a normal rise after medication with pancreatic enzymes. The new test is certainly more reliable, and easier and quicker, with the result the same day instead of after a 5 or 6 day collection of fxces, but it is not likely to be more sensitive than fxcal-fat mp5iQiiri-nit-nt
Nuffield Department of Clinical Biochemistry, Nuffield Department of Surgery, Radcliffe Infirmary,
W. A. F. PENFOLD. W. M. KEYNES.
Medical Professorial Unit St. Bartholomew’s Hospital, London E.C.1.
P. W. P. BUTLER G. M. BESSER.
A PREREGISTRATION PROBLEM
Oxford.
STEATORRHŒA AND PLASMA-ALKALINE-PHOSPHATASE a genetic explanation for the steatorplasma-alkaline-phosphatase of intestinal origin reported by Professor Dent and his colleagues (June 22, p. 1333). Intestinal lymphoma seems to be prevalent in nonAshkenazi Jews and Arabs in Israel.1-3 In such patients and their relatives, and in some patients with malabsorption alone, there is a high incidence of serum-alkaline-phosphatase intestinal isoenzyme; and in a few the serum-values are strikingly raised 11.4 The patient studied by Professor Dent and his colleagues was a Pakistani; perhaps patients of MiddleEastern or Asian origin with " idiopathic steatorrhoea should have their plasma-alkaline-phosphatase isoenzymes measured routinely to see whether they have a specific, perhaps genetically
SiR,—There
within these limits in each of our patients after successful treatment of their depression, when studied in the same environment, indicates that the pre-treatment abnormality is associated with the depressive illness rather than the environment.
may be
rhcea and raised
SIR,-Many of us share Professor Brooke’s concern in his letter last week (p. 1425) about the problems of the married preregistration house-officer and her child. In my Group we avoid the problem of asking the G.M.C. to amend their regulations. We provide married quarters for preregistration doctors whenever possible. The ingenuity, intelligence, and determination of the incumbents does the rest. High Moor, Wrightington, nr. Wigan, Lancs.
R. M. FORRESTER.
A SELECTIVE PORTACAVAL SHUNT
"
"
determined, malabsorotion svndrome. Prince of Wales’s General Hospital London N.15.
D. M. KRIKLER.
PITUITARY-ADRENAL FUNCTION IN DEPRESSION
SIR,-It is difficult
accept that the diurnal rhythm of levels was normal in our severely
to
plasma-hydrocortisone depressed patients (June 8, p. 1234) as suggested by Dr. Carrol and his colleagues (June 22, p. 1373). It is our experience, in agreement with Mattingly,5 Ross et al.,6 and others, that a fundamental feature of a normal diurnal rhythm is a midnight hydrocortisone level of less than 7 {jLg. per 100 ml. The diurnal rhythm in patients with Cushing’s syndrome is widely accepted as being " abnormal ". In this condition the highest hydrocortisone level may be found at midnight, as in our depressed patient 3, but not infrequently it is lower then than at 9 A.M. while undoubtedly still being elevated for this time of day. 6The midnight levels in our depressed patients 1
and 2 ranged between 13 and 20 tg. per 100 ml., and although lower than at 9 A.M. must be considered abnormal. Deviations from normality cannot be recognised by a comparison between 2 abnormal groups of patients. While it is of interest to compare depressed with other psychiatrically ill patients, the latter group cannot be used to define the normal range, as Dr. Carrol and his colleagues suggest. The lack of normal dexamethasone suppression reported in 3 of their non-depressed but psychiatrically ill patients supports the view that such patients cannot constitute a valid normal control population. Alternatively these results could be due to the reported inherent unreliability of the single-dose dexamethasone test employed.88 We have confirmed the published normal ranges for the diurnal rhythm of plasma-hydrocortisone levels obtained from convalescent non-stressed hospital patients.69 The return of the diurnal rhythm to 1. 2. 3. 4. 5. 6. 7. 8.
9.
Ramot, B., Shahin, N., Bubis, J. J. Israel. J. med. Sci. 1965, 1, 221. Eidelman, S., Parkins, R. A., Rubin, C. E. Medicine, Baltimore, 1966, 45, 111. Clinicopathological Conference. Israel J. med. Sci., 1968, 4, 164. Ramot, B., Streifler, C. Lancet, 1966, ii, 587. Mattingly, D. Proc. R. Soc. Med. 1963, 56, 717. Ross, E. J., Marshall-Jones, P., Friedman, M. Q. Jl. Med. 1966, 35, 149. Cope, C. L. Br. med. J. 1966, ii, 847. Connolly, C. K., Gore, M. B. R., Stanley, N., Wills, M. R. Br. med. J. 1968, ii, 665. Mattingly, D. in Recent Advances in Medicine (edited by D. N. Baron, N. Compston, and A. M. Dawson); p. 125. London, 1968.
SIR,-Although the standard portacaval shunt controls haemorrhage from oesophageal varices, there are several postoperative complications, such as Eck’s syndrome or hepatic failure, and the operation has not improved the survival-rate. In Japan, postnecrotic cirrhosis of the liver seems to be more common, and the direct portacaval shunt is contraindicated. Non-shunting surgical procedures have proved superior with regard to hepatic function, but are accompanied by nutritional imbalance and often recurrent bleeding. A new operative procedure has been developed in this department in which selective shunting is accomplished through the left gastric vein to the inferior vena cava (see accompanying figure). The rationale of the procedure is to decompress the area of oesophageal varices while maintaining a high portal pressure and providing adequate portal flow to the liver.
Selective shunt through left gastric vein
to
inferior
vena cava.
The dilated and engorged left gastric vein is dissected and severed as near as possible to the portal trunk, and the gastric stump is shunted to the inferior vena cava using an autogenous vein-graft taken from the great saphenous vein. In some situations, according to the anatomical variation, the left gastric vein is shunted to the right spermatic (or ovarian) vein directly, or to the left adrenal or renal vein with a vein-graft. The wall of the left gastric vein is often easily injured owing to the increased portal pressure and the resultant fibrosis, but use of our mechanical suturing instrument provides a simple and secure technique for the anastomosis, with a satisfactory result. In fact, no case has shown difficulty with this surgical
procedure.
52 Fifteen patients have been operated upon. Their liver function was impaired and the usual shunt operation was not indicated. All except two, in whom ascites and a hxmorrhagic were noted postoperatively owing to severe hepatic have made an uneventful postoperative recovery. damage, The mean left gastric venous pressure before operation (295 mm. water) decreased to 201 mm. water after the shunt, whereas the portal pressure was not changed by this procedure in most cases. Mean shunting blood-flow, measured by electromagnetic flow-meter, recorded 45-200 ml. per minute. (Esophageal varices, which had been noted preoperatively in all cases, have disappeared or have strikingly improved, and there has been no recurrent bleeding in any case during 10 months’ observation after the operation. Liver function and ammonium metabolism were only slightly influenced, suggesting that this procedure could be used with little risk even in patients with severe hepatic damage.
tendency
Increase in size and increase in basophilia of the cytoplasm was also noted in the lymphocytes of patients with aplastic anaemia treated with phytohxmagglutinin.3 We note also that unusual primitive, plasma-like cells were found in the lymphoid tissue and peripheral blood of small animals with E.A.E.4 To our knowledge such cells have not been described previously in human demyelinating diseases. Since E.A.E. is an example of autohypersensitivity it might not be imprudent to suggest that such cells might be observed in other autohypersensitivity diseases, and it would be of interest to know if they could be found in the peripheral blood of patients with multiple sclerosis. A complete account of the investigations on these patients and animals is in preparation for publication. Boston University Medical School, PETER O. BEHAN Veterans Administration Hospital,
Boston,
Although more experience is needed to make a definite evaluation, our new procedure is believed to widen the indications for the surgical treatment of oesophageal varices due
nortal hvnertension. Department of Surgery, Kyushu University Medical School, Fukuoka, Japan.
ORF
SiR,-Since there
to
are more
A NEW CELL IN DEMYELINATING DISEASE ?
SIR,-We report here an observation we have made on the peripheral blood of two patients, one with acute disseminated encephalomyelitis (A.D.E.M.), the other with acute haemorrhagic leucoencephalitis (A.H.L.E.), and on nine rhesus monkeys in which acute allergic encephalomyelitis (E.A.E.) was induced. One of the patients was thought clinically to have had a cerebral tumour and the diagnosis of A.H.L.E. was confirmed microscopically. E.A.E. was induced by a single injection of 500 µg. of a basic protein fraction of monkey centralnervous-system myelin (prepared and supplied by Dr. M. Kies of the National Institute of Mental Health) in Freund’s adjuvant containing killed mycobacteria. This was given intradermally into the left foot-pad of each animal and was followed after a variable period (average duration 16 days) by the clinical appearance of E.A.E. The diagnosis was confirmed by microscopy in each monkey. The abnormal cells (vide infra) were observed in the peripheral blood of the monkeys 4 days before the clinical onset of symptoms and were present when they were killed 4 days after onset of symptoms. In the patients, the cells were first noted in the one with A.H.L.E. in the early course of the disease, and were still present a month later when the patient was still very ill. In the second very small number of abnormal cells were still present two years after the onset of the disease. The cells have the appearance of abnormal lymphocytes. These vary from very large primitive cells up to 40 [L in diameter with large
sheep than men in Northumber-
bound to see the occasional case f orf. Whether our Newcastle dermatologists will see them is more doubtful, since the average country practitioner has more sense than to send a self-healing pustule 30 miles to hospital from a farm 2 miles from the nearest bus-stop. Surely a disease described as pustular dermatitis will at least be characterised by pustules rather than by weeping maculopapules, and the four cases that I have seen or imagined myself to have seen (electronically they might have been something else) were more in the nature of septic blisters without any fluid content, but with a thin layer of necrotic skin, easily cut away to reveal dark velvety granulations which I have seen described as characteristic (reference unfortunately not to hand). These cases cleared rapidly under a simple non-adherent dressing and in spite of intramuscular penicillin. Incidentally one was the wife of an affected shepherd who practically lived with his prize sheep-she had not been in direct contact with the sheep, and I have always regretted that I did not note the incubation period of this apparent human-
land, general practitioners KIYOSHI INOKUCHI.
JACQUES B. LAMARCHE.
Massachusetts 02130.
are
tn-human infection-
Amble, by Morpeth,
R. P. ROBERTSON.
Northumberland. 3. 4.
Humble, J. G. Lancet, 1964, i, 345. Dowling, P., Cook, S. Neurology, Minneap. 1968, 18, 295.
Diary of the Week
case a
nearly
nuclei containing nucleoli, and intensely basophilic cytoplasm with conspicuous small vacuoles, to atypical lymphocytes which vary from 12 fL to 20 [L in diameter, and have basophilic cytoplasm and nuclear chromatin of plasmacytoid type. In view of the current hypothesis that E.A.E., A.H.L.E., and A.D.E.M. are allergic in xtiology, and that the demyelination is caused by cellular mechanism of delayed sensitivity, such cells may be the immunoblasts involved in this reaction. One of us (P. 0. B.) has shown blastic transformation in short-term cultures of lymphocytes from both patients and from the monkeys, the specific mitogen being human and monkey encephalitogenic protein. Barker et al. described peripheralblood plasmacytosis with large " plasmacytoid lymphocytes " in the peripheral blood undergoing mitosis in patients after systemic exposure to Phytolacca americana (pokeweed).
basophilic
1. Kies, M. W., Murphy, J. B., Alvord, E. C., Jr., in Chemical Pathology of the Nervous System (edited by Folch-Pi); p. 197. Oxford, 1961. 2. Barker, B. E., Farnes, P., LaMarche, P. H. Pediatrics, Springfield, 1966, 38, 490.
JULY 7
TO
13
Tuesday, 9th ROYAL COLLEGE OF SURGEONS W.C.2 5 P.M. Mr. E. R. Owen:
OF
ENGLAND, Lincoln’s Inn Fields, London
Preventing the Rejection of Transplanted Organs. (Hunterian lecture.) ROYAL POSTGRADUATE MEDICAL SCHOOL, Ducane Road, London W.12 4 P.M. Mr. G. C. Knight: Stereotactic Tractotomy in Mental Illness.
Wednesday, 10th ROYAL COLLEGE OF SURGEONS OF ENGLAND 3 P.M. Prof. David Slome: Experimental Surgical Research at Downe. (Bernhard Baron lecture.) INSTITUTE OF CHILD HEALTH, 30 Guilford Street, London W.C.1 5.30 P.M. Dr. R. W. E. Watts: Cystinuria. INSTITUTE OF ORTHOPEDICS, 234 Great Portland Street, London W.1 8.15 P.M. Mr. P. H. Newman: Lumbosacral Subluxation and the Adolescent Growth Period. ROYAL FREE HOSPITAL, Gray’s Inn Road, London W.C.1 5.15 P.M. Dr. L. E. Siltzbach (New York): Pulmonary Aspergillosis.
Thursday, llth ROYAL POSTGRADUATE MEDICAL SCHOOL 4 P.M. Prof. H. H. Bentall: Heart-valve
Replacement.
Friday, 12th ROYAL POSTGRADUATE MEDICAL SCHOOL 10.15 A.M. Mr. J. C. Mustarde: Reconstruction Around the Orbit.