1100 TABLE I-RESULTS AFTER OBSERVATION OF AT LEAST
3
MONTHS IN WITHOUT AND WITH RADIOGRAPH AND
CASES "
OF
2
SNOWSTORM
"
patient when treatment is begun, despite the fact that it is based on somewhat imperfect clinical data, does constitute a useful prognostic guide. It is apparent that the clinical findings used in making this assessment " reflect a gradation of severity," and that in a proportion of the " late " cases the administration of streptomycin produces little alteration in the steady deterioration of
YEARS;
TUBERCULOUS
MENINGITIS APPEARANCE OF CHEST
the patient. D. M. DUNLOP
D. G. MCINTOSH G. L. MONTGOMERY J. D. Ross G. J. SUMMERS I. M. MACGREGOR
Chairman
T. ANDERSON D. BELL STANLEY GRAHAM
Medical Secretary.
CIRRHOSIS :
December, 1952-i.e., after a minimum follow-up period of 2 years and 3 months. Table i gives the results of treatment for the two main groups of cases-namely, patients’ with tuberculous snowstorm meningitis without an accompanying radiograph of the chest, and patients who, at any time during their treatment, presented evidence of both manifestations of the disease. It will be observed that for the series as a whole and for each of the two groups the proportion of results classified as " good " is the "
"
same-namely, approximately 40%.
Subdivision
of the cases into the three grades-early, and late-has confirmed the original that the best results have been obtained in
intermediate,
impression those patients
" on who were regarded as early for in this the of admission, group proportion satisfactory recoveries approaches 60%. The general validity of this clinical assessment as a prognostic guide is supported by the fact that, in those assessed as early " on admission, death was unusual during the initial period of treatment, whereas in those assessed as " late " a high proportion of the deaths occurred during the first 4 weeks in hospital "
"
(table II). Table
shows the number of deaths, the weekly and the number of survivors at intervals following admission to hospital. As would be expected, the mortality among survivors in each period progressively diminishes with the passage of time. This analysis may be briefly summarised. During a period of 2 years, 266 patients with tuberculous meningitis were treated with streptomycin at five Scottish n
fatality-rate,
centres. A follow-up of these patients 2 years and 3 months after the admission of the last case shows that. 105 (39%) were alive and regarded as excellent recoveries ; a further 20 patients were alive although their condition was regarded as unsatisfactory ; and the remainder-141-have died. It seems desirable to correct an earlier impression regarding the importance of the demonstration of a snowstorm " radiograph in patients with meningitis. In this larger series, such a finding seems of little prognostic value. On the other hand, the assessment of the "
TABLE
II-DEATHS, FATALITY-RATES,
*In the series
28 % were classified mediate," and 23 % as late." "
as
"
AND
early,"
SURVIVORSHIP
49
%
as
"
inter-
LIGATION OR ANASTOMOSIS?
SIR,—Professor McFadzean and Mr. Cook (March 28) that
hepatic-artery ligation has
been developed safe and effective substitute for attempt portacaval anastomosis. They admit that portacaval shunts prevent the recurrence of haematemesis and have a favourable effect on the ascites in the majority of these cases. Similar remarks were made in your editorial last year.1 I do not believe that any operation should be advocated simply because it is technically difficult, but neither should an effective operation be abandoned because of its difficulty. If this view were adopted we would all still be doing gastrojejunostomy instead of gastrectomy for chronic duodenal ulcer ! Furthermore, I believe that the difficulties and dangers of portacaval anastomosis have been grossly overestimated. The early results in this unit have been reported elsewhere2 and it was then noted that the operation carried a high mortalityrate in patients in whom splenectomy had -not been performed, but that in the first 9 patients in whom splenectomy had been performed as a preliminary measure there had been only 1 operative death. Since these cases were reported 6 further direct portacaval shunts have been done without operative death. The operation can be completed within two and a half hours. Only 1 patient, operated on four years ago, has had hæmatemesis, and the results of treatment on the whole have been very satisfactory. Against this background must be considered the results of hepatic-artery ligation as reported, and also as carried out in this unit. The clinical material in McFadzean and Cook’s series is presumably similar, for in Hong-Kong it is largely chance which determines whether the patient finds his way into the medical unit and has his hepatic artery tied, or into the surgical unit to get an Eck fistula. In this unit 4 patients have been subjected by way of a trial to hepatic-artery ligation. The first died with portal vein thrombosis, and the remaining 3 went steadily downhill. It was noted at operation that the fall in portal pressure, measured directly with a manometer, was quite inconstant after ligation of either splenic or hepatic arteries. Furthermore, it must be remembered that the peripheral resistance within the liver is increased in cirrhosis and flow is therefore dependent on maintenance of an adequate pressure. If the pressure in the portal vein falls and the hepatic arterial supply is removed, the total flow through the liver must fall. If the portal vein only is interrupted, blood continues to reach the liver at a high pressure through the hepatic artery and in these circumstances maintenance of adequate liver function in man is possible. It is well known that in a certain number of patients with cirrhosis splenectomy alone improves the clinical condition, and I am not yet convinced that the improvement which follows ligation of the hepatic artery, combined
plead
in
an
to find
a
1. Lancet, 1952, i, 1097. 2. Stock, F. E. Ann. R. Coll.
Surg. Engl. 1952, 10, 187.
1101
splenectomy Ithetithsplenectomy.
is due to the
ligation
rather than to
These considerations have led me to discard the operation of ligation of the hepatic artery and I continue to advocate splenectomy followed by portacaval anastoJ]1osis for any patient with cirrhosis, splenomegaly, and varices. FRANCIS E. STOCK University University of Hong-Kong.
tI BMphageal
Professor of Surgery.
CONTRACEPTIVE
TECHNIQUE
SiB,—The
letter from the managing director of Ortho pharmaceutical Ltd. should not satisfy anyone in charge of a birth-control clinic, and does not satisfy me, though it advertises further the contraceptives I " am warning and jelly Mr. George people about. The diaphragm entirely satisfactory praises I have long shown to be a not . technique.1 Though theoretically it would be very nice to have a suppository or substance that would do away with the necessity for any diaphragm cap or barrier, there are reasons which make this unlikely of achievement. Mr. George claims that their advertised product -Preceptin Vaginal Gel’-is safe without any barrier. First let me say it has to be placed with an applicator, and for general contraceptive use I condemn all methods the use of an applicator, which has many bad "
involving jehy-like
features. Further, a method involving the use only of a substance ignores the fact that in coitus the iperm may be ejaculated directly into the uterus, when none of the substance’s alleged unique capacity to destroy sperms would be able to take effect.2 The Ortho Research Foundation speaks of thousands of patients." What degree of safety after at least one year’s, and preferably two years’, consistent use of this as the only contraceptive do they claim ? We should be given also one or two addresses of recommended clinics in this country where this contraceptive has been consistently used, and the degree of success they record. "
C.B.C. Birth Control Clinic, 108, Whitfield Street, London, W.1.
’
MARIE C. STOPES President and Founder.
THE BRACHIAL-PALSY HAZARD SiR,—Though the Law may have to concern itself with a particular injury or an isolated event, doctors must try to regard the whole patient and his whole welfare. Recent interest in brachial-plexus injury subsequent to certain operating-table positions seems to illustrate this matter. Let us, for argument’s sake, admit that there is
a risk of brachial-plexus injury following maintained abduction of the arm under anesthesia. I believe that there are instances when the risk should forthrightly be accepted in the patient’s interest. Sometimes the continuance of an intravenous infusion is of critical importance to the patient because of collapse. Sometimes sudden and unpredicted interruption of the flow of the infusion might disrupt the smooth course of Mssthesia given by the method judged best for the patient’s survival, and such sudden disruption at a critical point in the operation could have grave consequences. In patients in a shocked state veins in the leg are often unsatisfactory, and an infusion into a forearm vein can easily fail unless the arm is accessible so that attention can be given immediately when needed. tnless the arm is abducted such attention is either impossible or imperfect. If the arm be only a little abducted the surgeon may be hampered by it and the patient’s interests thereby damaged. Even though it may expose me to the risk of being deemed negligent, I shall continue as occasion requires to place an infusion in a forearm vein, and abduct the arm onto an arm-board so that I can be as sure as 1. Stopes, M. C. Med. World, Lond. Nov. 23, 1951. 2. Stopes, M. C. Clin. Med. Surg. March, 1931.
humanly possible that the flow continues. I shall do this because I believe that the conscientious application of knowledge and judgment to the patient’s whole welfare will not infrequently demand it ; though I shall be fully aware of the small risk to his brachial plexus. Department of Anæsthesia, Royal Victoria Infirmary,
E. A. PASK.
Newcastle upon Tyne.
** * Dr. Pask can, we believe, pursue his course safely for the patient if he makes one small concession to the brachial plexus : by using the Jackman arm-rest1 he can prevent the abducted arm from falling below the coronal plane of the body. At the same time, we should point out that many other devices for protecting the brachial plexus are already in successful use.2-ED. L. INTESTINAL
OBSTRUCTION
IN
INFANTS
SiR,—It was never the intention in my letter of April 4 to decry in any way the invaluable part played by special centres in the advancement of neonatal surgery, and I question whether such an interpretation is justified. Psediatric surgical centres’ in Boston, Liverpool, and Stockholm, among others, have in a few years turned a mortality-rate of 75% in intestinal obstruction of the newborn (excluding meconium ileus) into a survival-rate of 75% or better-truly a remarkable achievement. Progress in medicine and surgery characteristically follows a pattern by which one or more main centres develop new methods of treatment or new surgical techniques, which - are later successfully adopted by others. Surely this process can be profitably applied to abdominal surgery in the newborn, where early diagnosis and treatment are essential. W. P. SWEETNAM. Halifax General Hospital. PEPTIC ULCERATION
interested in Dr. Csato’s account (May 16) of treatment of peptic ulceration with injections of chorionic gonadotropin. Some time ago I was struck by a statement by a patient with duodenal ulcer that her symptoms always remitted when she was pregnant. As she had failed to respond to the usual medical remedies, I gave her a course of ethinylcestradiol sublingually (to avoid the irritant effect of the drug on the gastric mucosa). There was an immediate resolution of symptoms in 2-3 days ; but when she suffered a further exacerbation some 6 months later, there was complete failure to reproduce the same Neither did she respond to ethisterone given in like manner. Since then I have tried both hormones in 5 other cases, and methyltestosterone in 3 male patients. Symptoms have been completely relieved by ethisterone in 1 case, and by ethinylcestradiol in another ; but in the remaining 6 cases there was no effect. In 1 case methyltestosterone greatly aggravated the pain. In view of Dr. Csato’s observations, I intend to treat some further cases with injections of progesterone, as opposed to the less reliable oral preparation. There is, perhaps, a slight tendency to take for granted the natural history of diseases, without inquiring more deeply into possible causes for spontaneous remissions and variations. Thus pregnancy has often been classed as one of many intercurrent conditions which may cause remission in such diverse diseases as peptic ulceration, disseminated sclerosis, and rheumatoid arthritis. Yet this observation on rheumatoid arthritis was one of the factors leading directly to the discovery of cortisone. DAVID WHEATLEY. Twickenham, Middlesex.
SIR,-I
1.
was
Wilson, E. F., Murphy, T. T. P., Angel, R. E. Lancet, 1951, i, 511. Ibid, 1950, i, 99; Kiloh, L., pp. 103, 121; Galley, A. H., Gray, A. J., p. 184; Finnie, W. J., p. 228; Lunn, M., Clutton-Brock, J., Clarke, S. H. C., Gusterson, E. R., p. 229; Lee, M., p. 277; Browne, J. C. M., Roberts, H., p. 278; FitzGerald. T. B., p. 326; Ward, R. O., Rollason, W. N., p. 423; Sinclair, A. D., p. 592.
2. Ewing, M. R.