472 g
half the demand for the better-known books. The orders mostly come from Spain, Holland, France, Bel-
gium, Hungary, Czechoslovakia, Scandinavia, Poland, and Russia. When the war ended Swiss publishers made a determined effort to capture Germany’s trade in medical books. The attempt met with little success, for these reasons : an antipathy, especially in Scandinavia, to the German language and to Germany ; the long isolation of Germany which caused her to lag in the
march of progress ; and the destruction of the German pharmaceutical industry. To those who live in Britain it may not have occurred that in these days of proprietary medicines the sale of textbooks goes largely hand in hand with the sale of drugs ; for the books explain the use of complex preparations whose title and constitution vary from one country to another. We stand in peril of missing a great opportunity ; for to achieve friendship with other nations we must impress them not only politically but functionally. Each textbook sent to Europe is one more link with a neighbour; and from such beginnings grows
understandind.
A Cause of Failure in Sympathectomy ? THE most pressing of the many unsolved problems in the surgery of the sympathetic nervous system is the recurrence of symptoms, particularly after operations for Raynaud’s disease or arterial hypertension. A variable period of improvement is too commonly followed by a relapse. Often the malady present precludes the possibility of anything more than fleeting improvement after sympathectomy-structural disease of the affected organs may be far advanced, or by nature progressive, and to operate at all may be regarded as an error of judgment. But apart from this group, in which the pathology of the lesion is to blame, there are many cases in which a physiological or anatomical explanation is perhaps more
probable.
a time it seemed that the secret of success would be found in practising preganglionic section, but HAXTONhas recently drawn attention to his work on Prof. E. D. TELFORD’S patients, and the researches of others in the same field, which show
For
Raynaud’s disease the results of this preganglionic operation in the upper limb are no better than those of ganglionectomy. It would be of great interest if a comparable series of patients operated on by the 2 more radical sympathectomy practised by SMITHWICK 3 that in
could be studied in the same way. In both TELFORD’S and SMITHWICK’S operations precautions are taken to prevent regeneration, which is known to take place readily in the sympathetic system and is believed, by those who favour the anatomical explanation, to be the chief cause of recurrent symptoms after sympa-
thectomy.
It is hard to believe that
preganglionic
fibres from the lower end of the severed thoracic sympathetic trunk can make their way across a gap of several centimetres, and in an entirely new direction, to join the upper end of the divided trunk which has been turned upwards, ensheathed in a silk envelope, and buried in the muscle of either the front or the Some alternative pathway for back of the neck. 1. Haxton, H. A. Brit. J. Surg. 1947, 35, 69. 2. Smithwick, R. H. New Engl. J. Med. 1940, 222, 699. 3. Telford, E. D. British Surgical Practice, London, 1947, p. 472.
sympathetic impulses
sought, and in this accessory (intermediate) sym-
must be
issue SKOOG’ describes pathetic ganglia in the rami communicantes of the cervical and upper thoracic sympathetic trunk which may perhaps provide such a pathway. Such accessory ganglia have already been described in relation to the spinal nerves and rami communicantes, as SKOOG points out, but by decalcifying the skeleton of the cervical spine he has been able to dissect and section for microscopic study the cervical and upper thoracic nerves, and their connexions with the sympathetic chain, more completely than has been possible before. This study shows the surgeon how he will miss a few sympathetic ganglion cells and fibres in performing a sympathectomy; and it is unfortunately true that, because of the chemical mediation of nerve impulses, even a minimal amount of tissue which has escaped removal can vitiate the result of the operation. These intermediate ganglia are inconstant in number and position. If they are present in relation to the 2nd and 3rd thoracic spinal nerve-roots they are unlikely to be removed unless the spinal nerves themselves are excised. This is an essential step in SMITHWICK’S operation, which was designed to interrupt the minute nerve filaments which are regarded as extra rami communicantes connecting the sympathetic trunk to the spinal nerve medial to the main rami. It is possible that these additional rami carry fibres to or from the intermediate ganglia described by SKOOG, and that some of them even run inside the spinal canal. These researches may pointthe way to modifications in surgical technique which will make the late results of
sympathectomy
more
reliable.
Diet and Cirrhosis GREAT advances have been made in elucidating the metabolic processes associated with the liver in health and disease since ÛPIE and ALFORD’, and DAVIS and WHIPPLE, first noted the protective effect of diet in experimental chloroform poisoning. Among the main contributions of the last decade have been the striking additions to our knowledge of the absorption, utilisation, and transportation of fat, especially the work of BEST and his colleagues, together with the researches on the role of the thio-amino-acids and the studies of WHIPPLE and his group on the plasma proteins, with their concept of the " dynamic equilibrium " of the proteins. In this time also our ideas concerning the aetiology of cirrhosis of the liver have changed as a result of fuller appreciation of the postnecrotic sequelae of infective hepatitis and through the experimental production both of acute hepatic necrosis and of cirrhosis by dietetic means rather than by the action of toxic chemical agents. In turn the diet adopted in hepatic disease has altered from the classical liver-sparing one, relatively low in protein, to one providing an adequate and probably high intake of complete proteins, with or without vitamin supplements ; and more recently the active treatment of cirrhosis has given patients a longer survival period with partial or complete freedom from ascites and other manifestations of the condition. Fat circulates in the blood, and is present in the liver, as neutral fat (glycerides), phospholipids, and cholesterol esters, having been ingested, mobilised from
473
favour its accumulation- there ; and the amount and possibly the kind of fat found in the liver, and any secondary results, largely depend on the balance of Choline is lipotropic, these factors in the diet. of its because action as an intact molecule probably the of fat facilitating transport by the formation of 2 Choline come lecithin. from the diet as such, may it as or or phospholipid, may be synthesised if a of labile sufficiency methyl groups can be supplied by the important sulphur-containing amino-acid methionine. Thus, in animal experiments, if the of other factors is not too great, choline, handicap and methionine lecithin, by their lipotropic action can cause excess of fat to be removed from, and thus restore to normal, a " fatty liver " previously impaired in function and susceptible to hepatic toxins. In man, however, the therapeutic effects of methionine and allied amino-acids have been less striking and with few exceptions not encouraging. BEATTIE et al.3 gave methionine at first by mouth and later intravenously in a case of accidental carbon tetrachloride poisoning with prompt regression of symptoms, and EDDY4 in two similar cases and in others of trinitrotoluene poisoning reported encouraging results and no deaths. BEATTIE and MARSHALL5 suggested that during arsenical treatment methionine, or casein digests rich in this amino-acid, could prevent or minimise liver damage ; but ’the results of choline and methionine treatment, particularly among troops with infective hepatitis, homologous serum jaundice, and postarsenical jaundice, were unconvincing. There was no clinical or laboratory evidence that these hepatic disorders were significantly benefited.s Cirrhosis of the liver in man may follow from repair of acute hepatic necrosis, as in some cases of infective hepatitis, or of toxic hepatitis due to different chemical agents; or -the cirrhosis may be insidious in onset and of ill-defined aetiology but associated with This distinction is necessary chronic alcoholism. not (though always easy, even after post-mortem examination), for the former is established and progressive, the result of a previous toxipathic lesion, while the latter is most probably dietetic, a process whose course, by deduction from morbid anatomical studies and by inference from animal experiment, can be altered by increasing the protein in the diet, while the patient can also be benefited by applying intensive supplementary therapeutic measures. Fatty infiltration of the liver has been reported as preceding diffuse hepatic fibrosis in the human subject, and in animal experiments, provided the fatty infiltration is sufficiently long maintained by giving a suitable
deficient diet, fibrosis results-in rats after 200-400 days and in dogs after 2-4 years. GLYNN has suggested that the induction of the cirrhosis is mechanical ; the fat-distended liver cells compress the sinusoids, the centrilobular cells suffer most from the circulatory interference and undergo atrophy, and fibrosis follows. In animals this cirrhosis can be prevented by adding sufficient lipotropic agents to the diet.7 In the last decade the exhibition of high-protein diets with supplements of choline, methionine, cystine, and vitamins of the B-complex, alone and combined, has given favourable results in some cases of hepatic cirrhosis in man. This has been chiefly in patients with enlarged livers, the probable high-fat content of which has been reduced by the lipotropic agents in the increased diet, the development of cirrhosis being thus arrested. In cases at the stage of established " decompensation " (ascites and oesophageal haemorrhages) results have been less promising. Thus in early cases PATEK8 reported that a balanced and nutritious diet with supplements of B-complex vitamins afforded a longer survival period and reduced ascites ; the twoyear survival-rate was about 45% of these patients With as against 22% in the untreated controls. similar intensive treatment and the addition of liver extract, MORISON9 recorded complete remission of ascites in 4 out of 9 cases as against none (out of 12) in a control group, while another group less intensively treated gave intermediate results. RALLietal.,10 studying comparable groups of cases similarly treated, but with intravenous liver extract as a supplement, have shown a 65% survival-rate after a two-year period. Now from the Rockefeller Institute LABBY et al.," co-workers of the late CHARLES L. HOAGLAND, report " " in a series of decompensated cases a survival-rate of 77% (23 out of 30) at the end of two years when a diet adequate in calories and proximate principles was combined with large quantities of a crude watersoluble alcohol-insoluble liver extract (Cohn’s fraction G) given intravenously for six months or longer. In 12 out of 21 patients the ascites disappeared completely within two to twelve months from the commencement of treatment, in 7 the frequency of paracentesis was reduced, and the remaining 2 were unaffected. The observation of periodic moderate diuresis some hours after the intravenous injection of the liver extract in these cases may be partial confirmation of the interesting report of RALLI and his associates 10 that in cirrhosis the liver is unable to destroy an antidiuretic substance (apparently from the hypophysis) which accumulates and appears in the urine. Nevertheless the results were probably so because good 70% of their patients were chronic alcohol addicts who benefited from full dietetic treatment rather than from the massive doses of crude liver extract they received. It is noteworthy that in the United States chronic alcoholics still form more than half the patients with cirrhosis, whereas in the Oxford area this association is now rarely seen.12 (Exportamu8 et vivimus I) If this be true generally in this country, less good results can be expected, since
1. Weir, J. F. J. Amer. med. Ass. 1947, 134, 579, 2. Perlman, I., Stillman, N., Chaikoff, I. L. J. biol. Chem. 1940, 133, 651. 3. Beattie, J., Herbert, P. H., Wechtel, C., Steele, C. W. Brit. med. J. 1944, i, 209. 4. Eddy, J. H. J. Amer. med. Ass. 1945, 128, 994; Amer. J. med. Sci. 1945, 210, 374. 5. Beattie. J., Marshall, J. Nature, Lond. 1944, 153, 525. 6. Witts, L. J. Brit. med. J. 1947, i, 45.
7. Glynn, L. E. Nutr. Abstr. Rev. 1947, 16, 751. 8. Patek, A. J. Bull. N.Y. Acad. Med. 1943, 19, 498. 9. Morison, L. M. Ann. intern. Med. 1946, 24, 792. 10. Ralli, E. P., Robson, J. S., Clarke, D., Hoagland, C. L. J. clin. Invest. 1945, 24, 316. 11. Labby, D. H., Shank, R. E., Kunkel, H. G., Hoagland, C. L. J. Amer. med. Ass. 1947, 133, 1181. 12. Kelsall, A. R., Stewart, A., Witts, L. J. Lancet, Aug. 9, p. 195.
depots, or synthesised by liver cells from carbohydrate and protein. The amount of fat in the liver is fairly constant (2-4%) if the diet contains sufficient protein and carbohydrate, and fat is continually being passed to or from the liver where it is " worked "-phosphorylation being a necessary part of the metabolic process. Lipotropic factors present in a normal diet facilitate the absorption and utilisation of fat and its mobilisation from the liver,while alipotropic factors
474 must infer’that most cases are toxipathic in origin and unlikely to benefit to the same remarkable extent from the dietetic and supplementary treatments outlined above. But before the value of supplements to the dietetic treatment of cirrhosis can be assessed truly, larger series of cases observed over long periods and with suitable group-controls will be necessary for statistical analysis. one
and thus be added to the list which already includes carriers of the causal organisms of bacillary dysentery, diphtheria, scarlet fever, and cerebrospinal fever.
HOPES AND FEARS IN INTERNATIONAL HEALTH THREE small clouds overhung the fourth session of the Interim Commission of the World Health Organisation, held at Geneva from Aug. 30 to Sept. 13. The first was the delay in ratification of the constitution of the Organisation, now signed by 64 countries but only ratified by 22, of whom 17 are members of the United Annotations Nations. The World Health Conference in New York in 1946, anticipated that the 26 ratifications of United July, COMPULSORY SEGREGATION OF CARRIERS ? Nations’ members necessary to establish the permanent NINE patients, who were presumably in the conorganisation would be forthcoming by the summer of valescent stage of paratyphoid fever, one of them being 1947. The delay is not due to opposition by any country ambiguously styled a "milk producer," lately walked or group to ratification-promises of ratification are out of a Bedfordshire isolation hospital before they two a penny-but to the inevitable lack of priority which were known to be free from infection. They were a non-controversial matter like health receives in a thus potential dangers to the community. The reason politically troubled world. The result is that the life of the remoteness for was this the Interim Commission is prolonged by at least a year, given premature departure of the hospital. Another, and more accessible, hospital until the summer of 1948, with all the consequential in which these patients would normally have been difficulties of programme, finance, and staff involved in treated was closed for lack of nurses. the continuation of an interim body beyond its expected The members of the hospital board were naturally period of existence. The Interim Commission has asked perturbed by the incident ; but, as the medical officer the chairman of the U.N. General Assembly to impress of health pointed out, there were no legal powers of on delegates the importance of early ratification, since detention. In England and Wales a M.o.H., under the essential progress in international health work is being Public Health (Infectious Diseases) Regulations, 1927, seriously hindered by the long delay in establishing the World Health Organisation." may require a suspected carrier of enteric or dysentery if the to medical and The second cloud was a financial one. A Republican examination ; undergo organisms carrier state is confirmed, the local authority may congress and the British financial crisis made it inevitable prohibit him or her, under heavy penalty and for a that the 1948 budget would not substantially exceed specified time, from handling food or drink for human that for 1947. Instead of the expanded programme, it consumption. The M.o.H. also has powers under the is doubtful if sufficient funds and staff have been provided Food and Drugs Act, 1938, to deal with dairy workers for the tasks already laid on the secretariat by the who may be in an infectious condition ; and here his commission. Indeed, the commission only just rescued authority is not limited to enteric or dysentery infections. itself from denying to its staff the allowances for maternity North of the Border, the Public Health (Infectious and hospital treatment to which they were already Diseases) Regulations (Scotland), 1932, give local entitled-a curious situation for a world health organisaauthorities wider powers ; a carrier of any disease tion. More important, many recommendations for field certified as such by a practitioner and the M.o.H. work and research made by the expert committees on malaria and tuberculosis were turned down, though may be isolated compulsorily, or otherwise controlled, The carrier for renewable periods of three months. provision for a team or two for B.c.G. vaccination was has the right of re-examination at any time, and made, a meeting of experts on streptomycin will be held, of appeal to the Department of Health. It seems and an expert committee on venereal diseases is to be desirable to confer similar powers in England and set up. Wales. Thirdly, the general deterioration in the political Usually a sense of responsibility to his family and the situation had some inevitable, though slight, reperpublic leads the patient or his parents -to accept isolation cussions. These were principally shown in the long until release is believed to be safe-belief can never debate on the place where the first World Health Assemamount to certainty because the carrier-state tends to bly should be held. Most European States, including the be intermittent. The long detention of patients after U.S.S.R., wanted Geneva on the grounds of working physical recovery is, at best, tedious. Adults sometimes facilities and economy ; the Latin Americans, U.S.A., Great Britain, and China favoured the western hemiworry about family or finance to a degree bordering on an anxiety state, whereas children, similarly cabined sphere, since all meetings of the Interim Commission, and confined, tend to become " hospitalised." Browning,l except the first, had been in Geneva. The western in his classical report on chronic enteric carriers, quoted hemisphere won by a considerable majority and the first Dittmar’s observation that most enteric carriers are World Health Assembly will probably be held about next May in New York, or in Canada if the United States women, whO’ may be unable to earn a living as cooks or dairy workers and therefore should be recompensed has not ratified by then. The next meeting of the the was the late in Interim Commission will be in Geneva in mid-January. by community (as Typhoid Mary the U.S.A.). Adult chronic carriers of any disease who More than 200 documents had to be considered, but, consent to isolation should at least not suffer financial with the help of three night sessions, this was accom’loss through no fault of their own. But the cure for the plished in the 13 days available, thanks to improved psychological and financial ills attendant on a protracted efficiency of the secretariat and the commission itself. carrier-state is to shorten the period of infectivity and Though it would be unfair to suggest that the contribuhence the duration of detention or restrictlon. So far, tions of members were in inverse ratio to the size of their the enteric carrier-state has proved resistant, or but delegations, the work done by some of the " singleton uncertainly responsive, to chemotherapy, but there can delegates was outstanding-notably Dr. K. Evang be little doubt that this too will yield to some future (Norway), Dr. C. Mani (India), and, considering his sulphonamide or antibiotic, alone or in combination, linguistic difficulties, Dr. N. Vinogradov (U.S.S.R.). Besides administrative and financial matters, which 1. Browning, C. H. Spec. Rep. Ser. med. Res. Coun., Lond. 1933, were discussed in great-perhaps too great-detail by no. 179, p. 26. "
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