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BIRTHDAY IN THE CRAFT
493
the
which is now recognised to be separand uterus. The ovarian innervation ate for ovary is bilateral and chiefly sympathetic, being derived from the renal, intermesenteric and coeliac plexuses. The ovarian nerves are two or three in number and their terminal ramifications end outside the theca externa of the follicle ; they pass no further, the membrana granulosa being nerveless. These sympathetic fibres are vasoconstrictor ; a few parasympathetic fibres provide a poorer and weaker vasodilator supply. The vasomotor effects of surgical denervation of the ovary are fortunately few, if any, because the hormonal control attends to the proper function of the ovarian cycle. Fertility and pregnancy are not adversely influenced ; only two of O’DONEL BRowNE’s cases married after ovarian denervation, but each has subsequently been success. nerve
path,
fully confined.
cases of primary dysmenorrhcea in which opened the abdomen, O’DoNE BROWNE found sclerocystic disease of the ovary, and he suggests that this is accompanied by perifascicular and intra-
In all
he
fascicular
nerve
in the
degeneration
similar to that found
presacral nerve in connexion with uterine dysmenorrhoea. This pathological change has been investigated and discussed by DAvis .3 As a control, O’DONEL BROWNE examined the ovarian nerves of undergoing hysterectomy who were known not to suffer from dysmenorrhoea, and in no case did he find a comparable nerve degeneration-a point which must be confirmed if possible by other workers. He explains the cyclic nature of the pain as being due to the pressure on the diseased nerveendings caused by premenstrual cedema. If the pain is more constant it is thought to be due to fibrosis in the region of the nerve-endings. He discusses the time-honoured cervical stenosis, so specious a cause of dysmenorrhoea in our fathers’ and forefathers’ time. Of all the cases he has examined for dysmenorrhoea only 1-2% had a genuine narrowing of the cervical canal. If a woman suffers from such severe menstrual pain as to warrant surgery after the failure of reasonable medical treatment, and if it is decided that she has ovarian dysmenorrhoea, the nerve path for her pain impulses must be destroyed. L’HERMITTE and DUPONT4 realised that this denervation must be bilateral, and they now advocate a division of the main ovarian nerve bundles in the mesovarium without interfering with the blood-supply. O’DoNEL BROWNE divides both infundibulo-pelvic ligaments, vessels and all, at the brim of the pelvis and securely ligates them with silk. The stumps at each side are sutured together distal to the silk ligature to prevent ovarian prolapse. The ovary is in no vascular jeopardy after this division ; the medial stump if unligated shows free arterial bleeding from the uterine anastomosis. women
A
presacral neurectomy, appendicectomy or Gilperformed according to the merits of the case. Of 16 cases so treated by O’DONEL BROWNE 10 are complete cures, while 6 are classed
liam’s operation is as
failures.
able,
Of these 6
no
less than 4
were
unsuit-
2 salpingitis and 1 tuberculosis. The corrected cure-rate is 5 in 6, a refreshing figure for any treatment of dysmenor1
having endometrioma,
3. Davis, A. A. J. Obstet. Gynæc. 1933, 40, 480. 4. L’Hermitte J. and Dupont, R. Gynéc et Obstét. 1927, 15, 161.
rhcea. O’DoNEL BROWNE’s denervation should be tested and reported on, so that we may know whether we have, if not the solution, at least a line of sound surgical attack on this problem.
Annotations BIRTHDAY
IN THE CRAFT
MEDICAL journalism is an old trade, going back perhaps to the famous code of Hammurabi, King of Babylon, who believed in punishing malpraxis by death and said as much in print. Medical journals, however, have not on the whole been notable for longevity. In the last century many mushroom ventures died, generally because they failed to fulfil promises made in a spacious mood at the start. Recently we had an opportunity in the columns of the British ]}[edical Journal to congratulate our crony of a hundred years on a long and honourable life ; this week we take pleasure in continuing those congratulations at more length. Birthdays, which loom so large in childhood, sink into welcome obscurity in middle age and only become subject for fresh enthusiasm when they indicate a high survival value. In medical journalism, as we have suggested, survival depends on the honest fulfilment of obligations-a criterion which might be extended to the human race with advantage. When Sir Charles Hastings founded the Provincial Medical and Surgical Association, its transactions were published annually ; but in 1840 the association founded a weekly, the Provincial JJ[edical and Surgical Journal, which later changed its name to the Association Medical Journal, and finally, in 1857, to the British Medical Journal. Allowing, then, for these nursery names the journal has achieved its century. If we can accept the old saying that the first hundred years is the worst, the future of our friend and rival will be of formidable brilliance, and it is comforting to reflect that being well launched on our own second century we share the same happy augury. But there are institutions to whom this birthday-consciousness-even for birthdays a hundred years apart-no doubt seems juvenile and immature. The colleges of our older universities, for example, might smile at such salad enthusiasms. When THE LANCET and the B.M.J. of three hundred years hence salute each other they will do it more casually. But speaking, as we do, in pinafores we are happy to think of a hundred years of sound medical record and criticism completed and we offer our best wishes for the centuries to come. WHAT IS LEUKÆMIA ? THE nature of human leukaemia is unknown and we still take cover in such meaningless cliches as the dim borderline of malignancy to hide our ignorance. There are three common theories-that it is caused by an unidentified infecting agent ; that there is a metabolic upset from an excess, deficiency or abnormal formation of an internal secretion ; or that the disease is a variety or perhaps varieties of malignant neoplasm. For each of these views there is circumstantial but little direct evidence. Among oblique methods of approach are the study of the chemical and cellular metabolism, the influence of heredity and various forms of trauma in animals and the behaviour of the pathological cells in tissue culture. Much work by reliable witnesses is on the side of the neoplastic theory but there are still many points to sort out. There is the widespread and so far as we know simultaneous involvement of many parts of the hsemopoietic system, the great differences in the clinical course of the disease, and the point made by Naegeli that infiltration of muscle by leuksemic cells destroys by compression and never by direct invasion. An explanation of these points is necessary, for until we can concentrate our efforts on a single and useful line of thought the chances of progress are poor. Tissue culture should
the
which is now recognised to be separand uterus. The ovarian innervation ate for ovary is bilateral and chiefly sympathetic, being derived from the renal, intermesenteric and coeliac plexuses. The ovarian nerves are two or three in number and their terminal ramifications end outside the theca externa of the follicle ; they pass no further, the membrana granulosa being nerveless. These sympathetic fibres are vasoconstrictor ; a few parasympathetic fibres provide a poorer and weaker vasodilator supply. The vasomotor effects of surgical denervation of the ovary are fortunately few, if any, because the hormonal control attends to the proper function of the ovarian cycle. Fertility and pregnancy are not adversely influenced ; only two of O’DONEL BRowNE’s cases married after ovarian denervation, but each has subsequently been success. nerve
path,
fully confined.
cases of primary dysmenorrhcea in which opened the abdomen, O’DoNE BROWNE found sclerocystic disease of the ovary, and he suggests that this is accompanied by perifascicular and intra-
In all
he
fascicular
nerve
in the
degeneration
similar to that found
presacral nerve in connexion with uterine dysmenorrhoea. This pathological change has been investigated and discussed by DAvis .3 As a control, O’DONEL BROWNE examined the ovarian nerves of undergoing hysterectomy who were known not to suffer from dysmenorrhoea, and in no case did he find a comparable nerve degeneration-a point which must be confirmed if possible by other workers. He explains the cyclic nature of the pain as being due to the pressure on the diseased nerveendings caused by premenstrual cedema. If the pain is more constant it is thought to be due to fibrosis in the region of the nerve-endings. He discusses the time-honoured cervical stenosis, so specious a cause of dysmenorrhoea in our fathers’ and forefathers’ time. Of all the cases he has examined for dysmenorrhoea only 1-2% had a genuine narrowing of the cervical canal. If a woman suffers from such severe menstrual pain as to warrant surgery after the failure of reasonable medical treatment, and if it is decided that she has ovarian dysmenorrhoea, the nerve path for her pain impulses must be destroyed. L’HERMITTE and DUPONT4 realised that this denervation must be bilateral, and they now advocate a division of the main ovarian nerve bundles in the mesovarium without interfering with the blood-supply. O’DoNEL BROWNE divides both infundibulo-pelvic ligaments, vessels and all, at the brim of the pelvis and securely ligates them with silk. The stumps at each side are sutured together distal to the silk ligature to prevent ovarian prolapse. The ovary is in no vascular jeopardy after this division ; the medial stump if unligated shows free arterial bleeding from the uterine anastomosis. women
A
presacral neurectomy, appendicectomy or Gilperformed according to the merits of the case. Of 16 cases so treated by O’DONEL BROWNE 10 are complete cures, while 6 are classed
liam’s operation is as
failures.
able,
Of these 6
no
less than 4
were
unsuit-
2 salpingitis and 1 tuberculosis. The corrected cure-rate is 5 in 6, a refreshing figure for any treatment of dysmenor1
having endometrioma,
3. Davis, A. A. J. Obstet. Gynæc. 1933, 40, 480. 4. L’Hermitte J. and Dupont, R. Gynéc et Obstét. 1927, 15, 161.
rhcea. O’DoNEL BROWNE’s denervation should be tested and reported on, so that we may know whether we have, if not the solution, at least a line of sound surgical attack on this problem.
Annotations BIRTHDAY
IN THE CRAFT
MEDICAL journalism is an old trade, going back perhaps to the famous code of Hammurabi, King of Babylon, who believed in punishing malpraxis by death and said as much in print. Medical journals, however, have not on the whole been notable for longevity. In the last century many mushroom ventures died, generally because they failed to fulfil promises made in a spacious mood at the start. Recently we had an opportunity in the columns of the British ]}[edical Journal to congratulate our crony of a hundred years on a long and honourable life ; this week we take pleasure in continuing those congratulations at more length. Birthdays, which loom so large in childhood, sink into welcome obscurity in middle age and only become subject for fresh enthusiasm when they indicate a high survival value. In medical journalism, as we have suggested, survival depends on the honest fulfilment of obligations-a criterion which might be extended to the human race with advantage. When Sir Charles Hastings founded the Provincial Medical and Surgical Association, its transactions were published annually ; but in 1840 the association founded a weekly, the Provincial JJ[edical and Surgical Journal, which later changed its name to the Association Medical Journal, and finally, in 1857, to the British Medical Journal. Allowing, then, for these nursery names the journal has achieved its century. If we can accept the old saying that the first hundred years is the worst, the future of our friend and rival will be of formidable brilliance, and it is comforting to reflect that being well launched on our own second century we share the same happy augury. But there are institutions to whom this birthday-consciousness-even for birthdays a hundred years apart-no doubt seems juvenile and immature. The colleges of our older universities, for example, might smile at such salad enthusiasms. When THE LANCET and the B.M.J. of three hundred years hence salute each other they will do it more casually. But speaking, as we do, in pinafores we are happy to think of a hundred years of sound medical record and criticism completed and we offer our best wishes for the centuries to come. WHAT IS LEUKÆMIA ? THE nature of human leukaemia is unknown and we still take cover in such meaningless cliches as the dim borderline of malignancy to hide our ignorance. There are three common theories-that it is caused by an unidentified infecting agent ; that there is a metabolic upset from an excess, deficiency or abnormal formation of an internal secretion ; or that the disease is a variety or perhaps varieties of malignant neoplasm. For each of these views there is circumstantial but little direct evidence. Among oblique methods of approach are the study of the chemical and cellular metabolism, the influence of heredity and various forms of trauma in animals and the behaviour of the pathological cells in tissue culture. Much work by reliable witnesses is on the side of the neoplastic theory but there are still many points to sort out. There is the widespread and so far as we know simultaneous involvement of many parts of the hsemopoietic system, the great differences in the clinical course of the disease, and the point made by Naegeli that infiltration of muscle by leuksemic cells destroys by compression and never by direct invasion. An explanation of these points is necessary, for until we can concentrate our efforts on a single and useful line of thought the chances of progress are poor. Tissue culture should