- Email: [email protected]
CLOSURE OF WOUNDS
503 vaccination the proportion of hospital cases was 2% for The low the vaccinated and 57% for the controls. inuitience of respiratory disease in the naval recruits was ascribed to penicillin prophylaxis, since the incidence of streptocoecal infection was low. During a comparable period in 1954, when no penicillin was given, streptococci were iolated from 50% of cases of respiratory disease in the camp. Infliienza vaccine was also used in both the military and naval recruits. In the army study the group vac. mated against influenza received no adenovirus vaccine. Thew had a similar incidence of respiratory disease to :he unvaceinated controls.
HÆMODIALYSIS FOR BARBITURATE POISONING
haemodialysis offers a rational means barbiturate intoxication by removing the treating poison from the body. Experimental work in dogs1 showed that haemodialysis could remove up to 40% of an invested dose of phenobarbitone from the body, and rather smaller amounts of the shorter-acting barbiturates. Berman et al.2 have successfully treated 8 patients with barbiturate poisoning by this method. An essential part of their regime is the repeated determination, by spectrophotometry, of the plasma level of barbiturate.3 One of Berman et al.’s patients took the incredible quantity of 25 g. of phenobarbitone. When admitted to the special unit forty-nine hours later she was deeply comatose and had a blood-barbiturate level of 253 mg. per 100 ml. It is a testimony to this treatment that she recovered, for it is very unlikely that conventional methods could have saved her life. After six hours of dialysis the blood-barbiturate level fell to 11-4 mg. per 100 ml. and the patient recovered consciousness. But a further rise in the barbiturate level followed, and two more dialyses were required before recovery was complete. Other cases in this series show that dialysis can reduce the blood-level of barbiturates, and can hasten the return of consciousness, after poisoning by phenobarbitone, barbitone, amylobarbitone, and the shortactinr barbiturates. Haemodialysis was most effective after poisoning by phenobarbitone, and when the bloodlevel of the drug was high. The technique of dialysis is complex, and not without hazards of its own ; but results such as these suggest ttut it may come to have an important place in the treatment of severe barbiturate poisoning. THE method of
of
HUMANISTS AND SCIENTISTS PHILOSOPHY has tended to become a specialism other specialisms, and many philosophers seem ; hf men who cultivate a particularly tidy way of talking bout ways of talking." In Prof. James Drever’s estimate, is one of the reasons why the humanist argues against cientific study of human behaviour and why he about the uses to which psychological knowhas been put. It is not so much the presumption ‘ ience which offends him as the abdication of philoProfessor Drever was addressing the Sheffield ting of the British Association last week. He tured the humanist pointing resolutely back into the Plato may help here, Rousseau there. " Every’- r..;worth saying has already been said, and the aim ’ ucation is to teach the young where they may "! But, Professor Drever observed, a man making porary decisions wanted contemporary guidance, .-. Tiett was where scientists were apt to be forced into . tion where they did not belong. The scientist could ther well in dealing with means and consequences ; ong
.
:plains
he could give advice about ends as well. But in the latter field the scientist had no special credentials ; and the humanist might be right to resent the undue consideration sometimes given to what his scientific colleague had to say on general matters. Professor Drever suggested that the remedy lay with the humanist himself. He should attempt to recapture the broad and speculative boldness of his predecessors. insight " He might not measure up to Plato, but at least he could do better than Monsieur Poujade or Joe McCarthy." The task of acquiring insight and speculative boldness was harder now than it had ever been, but it was also more important. If the humanist had something worth while to say, ordinary men would listen, but some of the others might be a trial. He must have an answer when the professional philosopher asked " Just what do you mean when you say that X is better than Y
perhaps
"
CLOSURE OF WOUNDS
THE
primary closure of skin wounds, whether surgical
traumatic, has interested surgeons for at least 35 centuries. During the long ages when no suture material was sterile and sepsis was inevitable, various attempts were made to close wounds without inserting stitches. The author of the Edwin Smith Papyrus, dealing with this subject in 1600 B.C. (or thereabouts), wrote : " If thou findest a wound open, thou shouldst draw together for him its gash with two strips of linen over that gash." An ingenious and less remote method, popular in the 19th century, was to transfix both wound margins by a straight needle, and hold the edges in contact by thread applied or
externally as a figure-of-eight. Recently Gillman and his colleagues1 have examined clinically and histologically the processes of primary healing, and, as a result, they became dissatisfied with the results of orthodox suturing. They found that the regenerating epithelium along the wound margins grew down towards the dermis, even when the wound was carefully sutured, and they regard this invasion of the dermis as " a consistent phenomenon in uncomplicated repair of cutaneous wounds." They also drew attention to the harm done by the actual stitches because of a similar epidermal downgrowth. Their tests on human volunteers involved making incised wounds on the forearm, where, incidentally, there is scanty subcutaneous tissue and skin margins are notoriously liable to invert. Having convinced themselves that sutures are less efficient and more harmful than is generally believed, Gillman et al. adopted an alternative technique-the closure of incised wounds with narrow strips of adhesive plastic tape.2 Pieces of ordinary stationery plastic tape are used, unsterilised. They are 21/2-3 in. long and 1/4 in. wide, and they are applied with narrow gaps between them, the wound edges being squeezed together to give good apposition. Gillman et al. say that " speedier and much better apposition of incised edges " is achieved by this method, and they propose " discarding sutures possible," even in entirely for skin closure whenever 3 has also had very Williamson major operations. a method. results with similar satisfactory Before these conclusions can be fully accepted, further research will clearly be needed. Comparisons will have to be made between the new method and the best efforts of skilled surgeons using orthodox techniques. Meanwhile, there remains for all surgeons an unaltered obligation to close wounds with such care that the result is, by the highest standards, inconspicuous and surgically sound. Fashions will change, but at present there is no better routine method of proven value than to use the 1.
1. Sunshine,
86, 638. J. Amer.
I., Leonards, J. R.
2. Berman, L. B., Jeghers. H.
Proc. Soc. exp. Biol., N.Y.
1954,
J., Schreiner, G. E., Pallotta, A. J. med. Ass. 1956, 161, 820. L. R. Analyt. Chem. 1952, 24, 1604.
3. Goldbaum,
Gillman, T., Penn, J., Bronks, D., Roux, M. Brit. J. Surg, 1955, 43, 141. Gillman, T., Penn, J. Medical Proceedings (Johannesburg), 1956, 2, 93. 2. Gillman, T., Penn, J., Bronks, D., Roux, M. Lancet, 1955, ii,
945. 3. Williamson, P.
Ibid, 1956, i,
206.
504 fine,st needles and suture materials ; to insert if necessary stitches to the inch ;
and to achieve many eight much tension. In certain eversion too without proper areas, such as forehead, eyelids, or neck, subcuticular sutures of wire or other material may give better results, since there is no need for early removal to avoid stitch marks. All these methods take time, but it would be a pity if any well-tried technique, widely applicable and highly reliable, was discarded because it made considerable demands on a surgeon’s patience or craftsmanship.
as
as
CHOLECYSTANGIOGRAPHY
’EXPERIENCE in the
use
of the intravenous contrast
medium, sodium iodipamide (’ Biligrafin,’ ’Cholografin ’), for the display of the biliary tract has been accumulating in the past three years, and clearer ideas of its uses and value are beginning to emerge. For the demonstration of the gall-bladder it is obviously superior to media given by mouth when the patient is vomiting or when absorption is impaired by diarrheea ; and it has another clear advantage when an early answer is wanted, as in acute abdominal conditions. On the other hand, though no deaths have been reported after its use, it has given rise to severe reactions.l-5 Moreover, it is a more timeand troublesome consuming procedure for the radiologist and his staff ; and it also has the theoretical disadvantage that it is concentrated in the liver, thus giving poorer evidence of gall-bladder function than the oral media, which are largely concentrated in the gallbladder itself. It seems undesirable, therefore, to use biligrafin when oral media will suffice. Most authors agree that in the routine investigation of the gall-bladder, oral cholecystography is still the method of first choice, and that intravenous cholecystography should follow only when there are clear indications for it. It is not indicated after a normal oral cholecystogram, which practically excludes gall-bladder disease,6unless the particular aim is to exclude a common-duct stone ; nor is it indicated by the finding of gall-stones, again unless it is important to examine the common duct for stones. It is indicated, however, when the findings of oral cholecystography are equivocal (and that includes a shadow of poor density) and when there is complete absence of filling. In that case, biligrafin may conclusively demonstrate gall-stones, or it may show the bile ducts without gall-bladder filling-a finding which reinforces the evidence of gall-bladder disease and which is often, though not invariably, associated with stones in the cystic duct.7 Occasionally, a gall-bladder which is not filled by oral cholecystography fills normally with biligrafin : it is certainly not safe to assume from this ambiguous result that the gall-bladder is normal, because Jordan 8 has recorded 4 such instances in which cholecystitis was found at operation. In the investigation of the postcholecystectomy patient, however, biligrafin seems9 the best agent, even though Twiss and his colleagues have shown that oral media can be used. In the so-called " postcholecystecintravenous eholangiography can tomy syndrome sometimes be decisive, by demonstrating stones in the but such common duct or in a cystic-duct remnant ; clear-cut findings are rare. Usually the biliary system looks normal or shows an abnormality of doubtful significance, such as a cystic-duct stump without stones. "
1.
Hornkiewytsch, T., Stender, H. S.
79, 292. 2. Hagedorn, H.
Fortschr. Röntgenstr. 1953,
Die Med. 1953, 2, 1693. 3. Ward, M. W. P. Lancet. 1954, 1, 887. 4. Lindblom, L. A. Svenska Läkartidn. 1955, 52, 4880. 5. Batt, R. C. Radiology, 1955, 65, 926. 6. Wickbom, I. G., Rentzhog, U. Acta radiol., Stockh. 1955, 44, 185. 7. Wise, R. E., O’Brien, R. G. J. Amer. med. Ass. 1956, 160, 819. 8. Jordan, P. H. jun. Surg. Gynec. Obstet. 1956, 102, 218. 9. Twiss, J. R., Beranbaum. S. A., Gillette, L., Poppel, M. H. Amer. J. med. Sci. 1954, 227, 372.
There is both clinical and pathological evidence 10 11 t these remnants are almost always accompanied inflammation and that their removal is beneficial. the other hand, McClenahan and his colleagues 12 f cystic-duct remnants nearly twice as often in a con series of symptom-free patients as in a group w
postcholecystectomy pain. Similarly open to dispute is the significance of dilata of the bile-ducts. Since the early work by Oddi on d it has been held that the bile-ducts undergo a sor postoperative physiological dilatation ; but if
maximum diameter of the normal duct (as meas on the radiographs) is accepted as 8 mm.,13 14 the is, in most cases, not abnormally dilated after ch cystectomy. Twiss et awl. consider that dilatation, w present, is evidence not of physiological dilatation bu "biliary dyskinesia"; Shehadi’s view 15 is that usual cause is stenosis or fibrosis of the sphincte Oddi ; and Wise and O’Brienbelieve that dilata indicates partial obstruction, but only when the meter exceeds 15 mm. On the other hand, Don Campbell 16 hold that all that can be inferred dilatation is that the duct has been obstructed at stage, usually in the past and by a stone, and that dilatation has proved irreversible. They found dil ducts just as commonly in symptom-free postcholecy ectomy patients as in those with symptoms, and conclude that this finding in the postcholecystect syndrome is of no significance. McClenahan et found a similar incidence of dilated ducts in sympt free patients compared with those who had pain Stasis in the bile-ducts, measured either by the after injection at which the opaque medium start enter the duodenum or by fading of the bile-duct sha also seems of doubtful significance in the postcholecys tomy syndrome, for wide variations in these times found in patients both with and without symptoms. Biligrafin provides a rough index of liver function,! this is seldom of practical value. With normal liver tion, the biliary tract will sometimes fail to opa although that is exceptional. With some reductio liver function, opacification is often impaired ; and severe liver damage the biliary tract can seldom be When there is jaundice due to obstruction or liver dam biligrafin is rarely successful in outlining the ducts, so it is of little value in the differential diagnosis the jaundice has cleared. In this respect biligrafin (methyl glucamine iodipamide in 50% solution), w has been recently introduced,18promises better results but even so it seems unlikely to be of value in
jaundiced patients.
10. Gray, H. K., Sharpe, W. S. Proc. Mayo Clin. 1944, 19. 11. Garlock, J. H., Hurwitt, E. S. Surgery, 1951, 29, 833. 12. McClenahan, J. L., Evans, J. A., Braunstein, P. W. J. med. Ass. 1955, 159, 1353. 13. Royer, M., Mazure, P., Kohan, S. Gastroenterology, 1950, 16, 14. Berk, J. E., Karnofsky, R. E., Shay, H., Stauffer, H. M. J. med. Sci. 1954, 227, 361. 15. Shehadi, W. H. Radiology, 1956, 76, 7. 16. Don, C., Campbell, D. H. J. Fac. Radiol. 1956, 7, 197. 17. Samuel, E., Gluckman, J., Barlow, J. Lancet, 1955. i. 13 18. Gaebel, E., Teschendorf, W. Fortschr. Röntgenstr. 1954, 81 19. Berk, J. E., Mellins, H. Z., Brodie, M. Amer. J. med 1956, 231, 289.
THE LANCET AIR-MAIL EDITION We now print a small proportion of our weekly is on India paper for transmission to distant countries air. The subscription rates for one year, inclusive air-mail postage, are: AUSTRALIA
AND
NEW ZEALAND.. S13 13 0
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AND
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Quotations on requ
LANCET, 7, Adam Street, Adelphi, London W.C
HÆMODIALYSIS FOR BARBITURATE POISONING
haemodialysis offers a rational means barbiturate intoxication by removing the treating poison from the body. Experimental work in dogs1 showed that haemodialysis could remove up to 40% of an invested dose of phenobarbitone from the body, and rather smaller amounts of the shorter-acting barbiturates. Berman et al.2 have successfully treated 8 patients with barbiturate poisoning by this method. An essential part of their regime is the repeated determination, by spectrophotometry, of the plasma level of barbiturate.3 One of Berman et al.’s patients took the incredible quantity of 25 g. of phenobarbitone. When admitted to the special unit forty-nine hours later she was deeply comatose and had a blood-barbiturate level of 253 mg. per 100 ml. It is a testimony to this treatment that she recovered, for it is very unlikely that conventional methods could have saved her life. After six hours of dialysis the blood-barbiturate level fell to 11-4 mg. per 100 ml. and the patient recovered consciousness. But a further rise in the barbiturate level followed, and two more dialyses were required before recovery was complete. Other cases in this series show that dialysis can reduce the blood-level of barbiturates, and can hasten the return of consciousness, after poisoning by phenobarbitone, barbitone, amylobarbitone, and the shortactinr barbiturates. Haemodialysis was most effective after poisoning by phenobarbitone, and when the bloodlevel of the drug was high. The technique of dialysis is complex, and not without hazards of its own ; but results such as these suggest ttut it may come to have an important place in the treatment of severe barbiturate poisoning. THE method of
of
HUMANISTS AND SCIENTISTS PHILOSOPHY has tended to become a specialism other specialisms, and many philosophers seem ; hf men who cultivate a particularly tidy way of talking bout ways of talking." In Prof. James Drever’s estimate, is one of the reasons why the humanist argues against cientific study of human behaviour and why he about the uses to which psychological knowhas been put. It is not so much the presumption ‘ ience which offends him as the abdication of philoProfessor Drever was addressing the Sheffield ting of the British Association last week. He tured the humanist pointing resolutely back into the Plato may help here, Rousseau there. " Every’- r..;worth saying has already been said, and the aim ’ ucation is to teach the young where they may "! But, Professor Drever observed, a man making porary decisions wanted contemporary guidance, .-. Tiett was where scientists were apt to be forced into . tion where they did not belong. The scientist could ther well in dealing with means and consequences ; ong
.
:plains
he could give advice about ends as well. But in the latter field the scientist had no special credentials ; and the humanist might be right to resent the undue consideration sometimes given to what his scientific colleague had to say on general matters. Professor Drever suggested that the remedy lay with the humanist himself. He should attempt to recapture the broad and speculative boldness of his predecessors. insight " He might not measure up to Plato, but at least he could do better than Monsieur Poujade or Joe McCarthy." The task of acquiring insight and speculative boldness was harder now than it had ever been, but it was also more important. If the humanist had something worth while to say, ordinary men would listen, but some of the others might be a trial. He must have an answer when the professional philosopher asked " Just what do you mean when you say that X is better than Y
perhaps
"
CLOSURE OF WOUNDS
THE
primary closure of skin wounds, whether surgical
traumatic, has interested surgeons for at least 35 centuries. During the long ages when no suture material was sterile and sepsis was inevitable, various attempts were made to close wounds without inserting stitches. The author of the Edwin Smith Papyrus, dealing with this subject in 1600 B.C. (or thereabouts), wrote : " If thou findest a wound open, thou shouldst draw together for him its gash with two strips of linen over that gash." An ingenious and less remote method, popular in the 19th century, was to transfix both wound margins by a straight needle, and hold the edges in contact by thread applied or
externally as a figure-of-eight. Recently Gillman and his colleagues1 have examined clinically and histologically the processes of primary healing, and, as a result, they became dissatisfied with the results of orthodox suturing. They found that the regenerating epithelium along the wound margins grew down towards the dermis, even when the wound was carefully sutured, and they regard this invasion of the dermis as " a consistent phenomenon in uncomplicated repair of cutaneous wounds." They also drew attention to the harm done by the actual stitches because of a similar epidermal downgrowth. Their tests on human volunteers involved making incised wounds on the forearm, where, incidentally, there is scanty subcutaneous tissue and skin margins are notoriously liable to invert. Having convinced themselves that sutures are less efficient and more harmful than is generally believed, Gillman et al. adopted an alternative technique-the closure of incised wounds with narrow strips of adhesive plastic tape.2 Pieces of ordinary stationery plastic tape are used, unsterilised. They are 21/2-3 in. long and 1/4 in. wide, and they are applied with narrow gaps between them, the wound edges being squeezed together to give good apposition. Gillman et al. say that " speedier and much better apposition of incised edges " is achieved by this method, and they propose " discarding sutures possible," even in entirely for skin closure whenever 3 has also had very Williamson major operations. a method. results with similar satisfactory Before these conclusions can be fully accepted, further research will clearly be needed. Comparisons will have to be made between the new method and the best efforts of skilled surgeons using orthodox techniques. Meanwhile, there remains for all surgeons an unaltered obligation to close wounds with such care that the result is, by the highest standards, inconspicuous and surgically sound. Fashions will change, but at present there is no better routine method of proven value than to use the 1.
1. Sunshine,
86, 638. J. Amer.
I., Leonards, J. R.
2. Berman, L. B., Jeghers. H.
Proc. Soc. exp. Biol., N.Y.
1954,
J., Schreiner, G. E., Pallotta, A. J. med. Ass. 1956, 161, 820. L. R. Analyt. Chem. 1952, 24, 1604.
3. Goldbaum,
Gillman, T., Penn, J., Bronks, D., Roux, M. Brit. J. Surg, 1955, 43, 141. Gillman, T., Penn, J. Medical Proceedings (Johannesburg), 1956, 2, 93. 2. Gillman, T., Penn, J., Bronks, D., Roux, M. Lancet, 1955, ii,
945. 3. Williamson, P.
Ibid, 1956, i,
206.
504 fine,st needles and suture materials ; to insert if necessary stitches to the inch ;
and to achieve many eight much tension. In certain eversion too without proper areas, such as forehead, eyelids, or neck, subcuticular sutures of wire or other material may give better results, since there is no need for early removal to avoid stitch marks. All these methods take time, but it would be a pity if any well-tried technique, widely applicable and highly reliable, was discarded because it made considerable demands on a surgeon’s patience or craftsmanship.
as
as
CHOLECYSTANGIOGRAPHY
’EXPERIENCE in the
use
of the intravenous contrast
medium, sodium iodipamide (’ Biligrafin,’ ’Cholografin ’), for the display of the biliary tract has been accumulating in the past three years, and clearer ideas of its uses and value are beginning to emerge. For the demonstration of the gall-bladder it is obviously superior to media given by mouth when the patient is vomiting or when absorption is impaired by diarrheea ; and it has another clear advantage when an early answer is wanted, as in acute abdominal conditions. On the other hand, though no deaths have been reported after its use, it has given rise to severe reactions.l-5 Moreover, it is a more timeand troublesome consuming procedure for the radiologist and his staff ; and it also has the theoretical disadvantage that it is concentrated in the liver, thus giving poorer evidence of gall-bladder function than the oral media, which are largely concentrated in the gallbladder itself. It seems undesirable, therefore, to use biligrafin when oral media will suffice. Most authors agree that in the routine investigation of the gall-bladder, oral cholecystography is still the method of first choice, and that intravenous cholecystography should follow only when there are clear indications for it. It is not indicated after a normal oral cholecystogram, which practically excludes gall-bladder disease,6unless the particular aim is to exclude a common-duct stone ; nor is it indicated by the finding of gall-stones, again unless it is important to examine the common duct for stones. It is indicated, however, when the findings of oral cholecystography are equivocal (and that includes a shadow of poor density) and when there is complete absence of filling. In that case, biligrafin may conclusively demonstrate gall-stones, or it may show the bile ducts without gall-bladder filling-a finding which reinforces the evidence of gall-bladder disease and which is often, though not invariably, associated with stones in the cystic duct.7 Occasionally, a gall-bladder which is not filled by oral cholecystography fills normally with biligrafin : it is certainly not safe to assume from this ambiguous result that the gall-bladder is normal, because Jordan 8 has recorded 4 such instances in which cholecystitis was found at operation. In the investigation of the postcholecystectomy patient, however, biligrafin seems9 the best agent, even though Twiss and his colleagues have shown that oral media can be used. In the so-called " postcholecystecintravenous eholangiography can tomy syndrome sometimes be decisive, by demonstrating stones in the but such common duct or in a cystic-duct remnant ; clear-cut findings are rare. Usually the biliary system looks normal or shows an abnormality of doubtful significance, such as a cystic-duct stump without stones. "
1.
Hornkiewytsch, T., Stender, H. S.
79, 292. 2. Hagedorn, H.
Fortschr. Röntgenstr. 1953,
Die Med. 1953, 2, 1693. 3. Ward, M. W. P. Lancet. 1954, 1, 887. 4. Lindblom, L. A. Svenska Läkartidn. 1955, 52, 4880. 5. Batt, R. C. Radiology, 1955, 65, 926. 6. Wickbom, I. G., Rentzhog, U. Acta radiol., Stockh. 1955, 44, 185. 7. Wise, R. E., O’Brien, R. G. J. Amer. med. Ass. 1956, 160, 819. 8. Jordan, P. H. jun. Surg. Gynec. Obstet. 1956, 102, 218. 9. Twiss, J. R., Beranbaum. S. A., Gillette, L., Poppel, M. H. Amer. J. med. Sci. 1954, 227, 372.
There is both clinical and pathological evidence 10 11 t these remnants are almost always accompanied inflammation and that their removal is beneficial. the other hand, McClenahan and his colleagues 12 f cystic-duct remnants nearly twice as often in a con series of symptom-free patients as in a group w
postcholecystectomy pain. Similarly open to dispute is the significance of dilata of the bile-ducts. Since the early work by Oddi on d it has been held that the bile-ducts undergo a sor postoperative physiological dilatation ; but if
maximum diameter of the normal duct (as meas on the radiographs) is accepted as 8 mm.,13 14 the is, in most cases, not abnormally dilated after ch cystectomy. Twiss et awl. consider that dilatation, w present, is evidence not of physiological dilatation bu "biliary dyskinesia"; Shehadi’s view 15 is that usual cause is stenosis or fibrosis of the sphincte Oddi ; and Wise and O’Brienbelieve that dilata indicates partial obstruction, but only when the meter exceeds 15 mm. On the other hand, Don Campbell 16 hold that all that can be inferred dilatation is that the duct has been obstructed at stage, usually in the past and by a stone, and that dilatation has proved irreversible. They found dil ducts just as commonly in symptom-free postcholecy ectomy patients as in those with symptoms, and conclude that this finding in the postcholecystect syndrome is of no significance. McClenahan et found a similar incidence of dilated ducts in sympt free patients compared with those who had pain Stasis in the bile-ducts, measured either by the after injection at which the opaque medium start enter the duodenum or by fading of the bile-duct sha also seems of doubtful significance in the postcholecys tomy syndrome, for wide variations in these times found in patients both with and without symptoms. Biligrafin provides a rough index of liver function,! this is seldom of practical value. With normal liver tion, the biliary tract will sometimes fail to opa although that is exceptional. With some reductio liver function, opacification is often impaired ; and severe liver damage the biliary tract can seldom be When there is jaundice due to obstruction or liver dam biligrafin is rarely successful in outlining the ducts, so it is of little value in the differential diagnosis the jaundice has cleared. In this respect biligrafin (methyl glucamine iodipamide in 50% solution), w has been recently introduced,18promises better results but even so it seems unlikely to be of value in
jaundiced patients.
10. Gray, H. K., Sharpe, W. S. Proc. Mayo Clin. 1944, 19. 11. Garlock, J. H., Hurwitt, E. S. Surgery, 1951, 29, 833. 12. McClenahan, J. L., Evans, J. A., Braunstein, P. W. J. med. Ass. 1955, 159, 1353. 13. Royer, M., Mazure, P., Kohan, S. Gastroenterology, 1950, 16, 14. Berk, J. E., Karnofsky, R. E., Shay, H., Stauffer, H. M. J. med. Sci. 1954, 227, 361. 15. Shehadi, W. H. Radiology, 1956, 76, 7. 16. Don, C., Campbell, D. H. J. Fac. Radiol. 1956, 7, 197. 17. Samuel, E., Gluckman, J., Barlow, J. Lancet, 1955. i. 13 18. Gaebel, E., Teschendorf, W. Fortschr. Röntgenstr. 1954, 81 19. Berk, J. E., Mellins, H. Z., Brodie, M. Amer. J. med 1956, 231, 289.
THE LANCET AIR-MAIL EDITION We now print a small proportion of our weekly is on India paper for transmission to distant countries air. The subscription rates for one year, inclusive air-mail postage, are: AUSTRALIA
AND
NEW ZEALAND.. S13 13 0
(sterli
UNITED STATES, CANADA, SOUTH
AFRICA, OTHER THE
AND
INDI
COUNTRIES
....£11 11 0
....
(sferli
Quotations on requ
LANCET, 7, Adam Street, Adelphi, London W.C