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DIVISION OF INTERCOSTAL ARTERIES
146 POSTOPERATIVE COLLAPSE DUE TO ADRENAL INSUFFICIENCY
SIR,—In their very interesting article Mr. Slaney and Mr. Brooke (June 8) make the point that adrenal glands which have been depressed by cortisone therapy, while capable of producing enough steroids for ordinary daily requirements, may be unable to meet the additional requirements of severe stress. May I ask what is the stress of any particular operation ? What would be of profound interest and a valuable addition to their work would be details of the anaesthetic drugs used in their cases. I think the depressed adrenals are very susceptible to poisonous drugs, and anything in the nature of histotoxic anaesthesia should be used sparingly, if at all, in such circumstances. Most patients will stand any operation and any anaesthetic for a short period, but the longer the procedure the weaker must be the anaesthetic, and as I have pointed out,’ it is often the anaesthetist’s efforts to protect his patient from shock that bring about this very thing. .
age. A colleague has grown a geranium plant under similar conditions. Your correspondents do not state whether the pots in question are made of china or enamel, but either of these should Drove satisfactory. G. A. SCHMEIDLER. THE LIVER IN HÆMOCHROMATOSIS
SIR,—In his letter of May 11, and in previous studies mentioned therein, Dr. Higginson raises several con. tentious issues. May we briefly outline some relevant facts recorded by other workers, so that investigators abroad will not be confounded by the apparent confusion of facts emanating from South Africa? Among facts previously published by others, and more recently emerging from our own studies in Durban, are :
1. Iron uptake, and in consequence hepatic siderosis, has consistently been shown to be much greater in several " species of animals fed a bad " diet as opposed to a good " one of equal iron content.1-3 2. As for iron absorption in African siderotics, while recognising the fine preliminary effort made by Bothwell et J. SHEGOG RUDDELL. awl. to solve this problem by the use of radioactive iron, it should be noted that of the five African siderotics studied DIVISION OF INTERCOSTAL ARTERIES by these workers three were females, three manifested diabetes SIR,—The statement by Jean Cauchoix and Jean-Paul (admittedly rare even in severe African siderotics), three were more than 60 years old, and all five were stated to be Binet that the question of how many intercostal arteries severely siderotic when their iron uptake was tested. These still remains can be divided unanswered is safely five cases may, perhaps, already have been fairly " saturated’’ true in its to interference with undoubtedly application with iron. Consequently, we would not regard them as a the blood-supply of the spinal cord. group representative of Africans with active siderosis. It Descriptions of the blood-supply of the cord by Kadyi should be remembered, too, that severe European hsemoand by Suh and Alexander (referred to by Mr. Hodgson chromatotics do not consistently take up radioactive iron in his letter of June 22) have established the generally in excess of normal.5 We may also mention that there is accepted pattern of vascularisation, but some of the reason to believe that the apparently pathological excess of dietary iron in the African may ultimately be possible variations in this pattern have not yet been uptake found to vary seasonally, even in the same individual, as described. do other pathological conditions among Africans,* more I have recently completed a study of this problem and especially kwashiorkor and pellagra. have examined a total of 68 cords. The results of this 3. Strachan, Gillman and Gillman,’-9 and Becker 10 in investigation agree with those of previous workers in Johannesburg, and more recently Gillman,11 Gilhnan et al.,"2 that in most individuals the main supply to the lower and Wainwright 13 in Durban, from the study of a combined part of the cord comes from the lower thoracic and upper total of between one and two thousand adult African livers. all found that severe siderosis (i.e., hepatic iron contents of lumbar segmental arteries. There are, however, a small 0-2 to 5-4%, or about 2 to 50 times greater than the upper number of notable exceptions, for in several cases there limits of normal) occurs in approximately 65-88% of male has been only one anterior radicular artery of any African livers obtained from a variety of sources in the "
*’
significant size below the cervical region. In one instance this was found arising from the posterior branch of the
Union.
4. Our analysis thus far, of the first 170 of 200 liver biopsies from adult African males in Durban, revealed siderosis in over 75% and cirrhosis in 36%. Among the 62 cases of frank cirrhosis, siderotic (portal) cirrhosis was found in 41 (66%), post-necrotic scarring in 14 (23%), and a combination of these two lesions in 7 (11%). These findings broadly conform with those of Gillman and Gillman 7-9 Becker 10 and even with the 1953 report of Higginson et al.14 In this latter report these workers stated that 25 (72%) of their 35 cirrhotics were suffering from a form of cirrhosis which was " .. clearls a more advanced degree of the fine portal Anatomy Department, usually J. B. D. TORR. University of Manchester. being associated with severe siderosis and showing " minima bile duct hyperplasia." Only 9 (26%) of the 35 cirrhotic A THOUSAND CHAMBER POTS livers studied by them at that time " showed a coarse multi SIR,—Dr. Munro and Mr. Williamson (July 6) pose anLlobular cirrhosis "-the latter presumably referring to post In 1957, however, Higginson et aU administrative problem : how to dispose of a thousandnecrotic scarring.
6th left intercostal artery and in four other instances from the similar branch of the 8th left intercostal artery. From the anatomical appearances it would seem that individuals possessing this type of blood-supply to the spinal cord would be very likely to suffer some degree oj cord damage should they have to undergo any operativf procedure interrupting the circulation through the lower half of the thoracic aorta or its intercostal branches.
type "
unwanted chamber pots in a mental hospital. Considering that mental hospitals always seem to possess beautifully tended gardens and that one also often finds a great many indoor plants in these hospitals, it might be an idea to use these pots for growing and propagating such plants. It is generally stated that for a plant to grow successfully it is essential for the pot in which the plant grows to have a hole at the bottom in order to allow for proper drainage, and this is of course by far the safest thing to do. I have, however, successfully grown some quite presentable specimens of tradescantia in glazed vessels containing instead of the crocked hole at the bottom a layer of pebbles and vermiculite for drain1. Ruddell, J. S.
Brit. med. J.
1956, i, 925.
Kinney, T. D., Hegsted, D. M., Finch, C. E. J. exp. Med. 1949, 90, 137. 2. Rather, L. J. Amer. J. Med. 1956, 21, 857. 3. Finch, C. A., et al. Blood, 1950, 5, 938. 4. Bothwell, T. H., van Doorn-Wittkampf, H. van W., duPreez, M. L., Alper, T. J. Lab. clin. Med. 1953, 41, 836. 5. Finch, S. C., Finch, C. A. Medicine, 1955, 34, 381. 6. Strachan, A. S. M.D. thesis Glasgow, 1929. 7. Gillman, J., Gillman, T. Arch. Path. 1945, 40, 239. 8. Gillman, J., Gillman, T. Lancet, 1948, i, 169. 9. Gillman, J., Gillman, T. Perspectives in Human Malnutrition. New York, 1951. 10. Becker, B. J. P. Leech, 1944, 15, 15. 11. Gillman, T. Ciba Colloquia on Ageing, 1957, 3, pp. 104, 188. 12. Gillman, T., Lamont, N. McE., Hathorn, M., Canham, P. A. S. Lancet, 1957, ii (in the press). 13. Wainwright, J. S. Afr. J. Lab. clin. Med. 1957, 3, 1. 14. Higginson, J., Gerritsen, T., Walker, A. R. P. Amer. J. Path. 1953, 29, 779. 15. Higginson, J., Grobbelaar, B. G., Walker, A. R. P. Ibid, 1957, 33, 29. 1.
SIR,—In their very interesting article Mr. Slaney and Mr. Brooke (June 8) make the point that adrenal glands which have been depressed by cortisone therapy, while capable of producing enough steroids for ordinary daily requirements, may be unable to meet the additional requirements of severe stress. May I ask what is the stress of any particular operation ? What would be of profound interest and a valuable addition to their work would be details of the anaesthetic drugs used in their cases. I think the depressed adrenals are very susceptible to poisonous drugs, and anything in the nature of histotoxic anaesthesia should be used sparingly, if at all, in such circumstances. Most patients will stand any operation and any anaesthetic for a short period, but the longer the procedure the weaker must be the anaesthetic, and as I have pointed out,’ it is often the anaesthetist’s efforts to protect his patient from shock that bring about this very thing. .
age. A colleague has grown a geranium plant under similar conditions. Your correspondents do not state whether the pots in question are made of china or enamel, but either of these should Drove satisfactory. G. A. SCHMEIDLER. THE LIVER IN HÆMOCHROMATOSIS
SIR,—In his letter of May 11, and in previous studies mentioned therein, Dr. Higginson raises several con. tentious issues. May we briefly outline some relevant facts recorded by other workers, so that investigators abroad will not be confounded by the apparent confusion of facts emanating from South Africa? Among facts previously published by others, and more recently emerging from our own studies in Durban, are :
1. Iron uptake, and in consequence hepatic siderosis, has consistently been shown to be much greater in several " species of animals fed a bad " diet as opposed to a good " one of equal iron content.1-3 2. As for iron absorption in African siderotics, while recognising the fine preliminary effort made by Bothwell et J. SHEGOG RUDDELL. awl. to solve this problem by the use of radioactive iron, it should be noted that of the five African siderotics studied DIVISION OF INTERCOSTAL ARTERIES by these workers three were females, three manifested diabetes SIR,—The statement by Jean Cauchoix and Jean-Paul (admittedly rare even in severe African siderotics), three were more than 60 years old, and all five were stated to be Binet that the question of how many intercostal arteries severely siderotic when their iron uptake was tested. These still remains can be divided unanswered is safely five cases may, perhaps, already have been fairly " saturated’’ true in its to interference with undoubtedly application with iron. Consequently, we would not regard them as a the blood-supply of the spinal cord. group representative of Africans with active siderosis. It Descriptions of the blood-supply of the cord by Kadyi should be remembered, too, that severe European hsemoand by Suh and Alexander (referred to by Mr. Hodgson chromatotics do not consistently take up radioactive iron in his letter of June 22) have established the generally in excess of normal.5 We may also mention that there is accepted pattern of vascularisation, but some of the reason to believe that the apparently pathological excess of dietary iron in the African may ultimately be possible variations in this pattern have not yet been uptake found to vary seasonally, even in the same individual, as described. do other pathological conditions among Africans,* more I have recently completed a study of this problem and especially kwashiorkor and pellagra. have examined a total of 68 cords. The results of this 3. Strachan, Gillman and Gillman,’-9 and Becker 10 in investigation agree with those of previous workers in Johannesburg, and more recently Gillman,11 Gilhnan et al.,"2 that in most individuals the main supply to the lower and Wainwright 13 in Durban, from the study of a combined part of the cord comes from the lower thoracic and upper total of between one and two thousand adult African livers. all found that severe siderosis (i.e., hepatic iron contents of lumbar segmental arteries. There are, however, a small 0-2 to 5-4%, or about 2 to 50 times greater than the upper number of notable exceptions, for in several cases there limits of normal) occurs in approximately 65-88% of male has been only one anterior radicular artery of any African livers obtained from a variety of sources in the "
*’
significant size below the cervical region. In one instance this was found arising from the posterior branch of the
Union.
4. Our analysis thus far, of the first 170 of 200 liver biopsies from adult African males in Durban, revealed siderosis in over 75% and cirrhosis in 36%. Among the 62 cases of frank cirrhosis, siderotic (portal) cirrhosis was found in 41 (66%), post-necrotic scarring in 14 (23%), and a combination of these two lesions in 7 (11%). These findings broadly conform with those of Gillman and Gillman 7-9 Becker 10 and even with the 1953 report of Higginson et al.14 In this latter report these workers stated that 25 (72%) of their 35 cirrhotics were suffering from a form of cirrhosis which was " .. clearls a more advanced degree of the fine portal Anatomy Department, usually J. B. D. TORR. University of Manchester. being associated with severe siderosis and showing " minima bile duct hyperplasia." Only 9 (26%) of the 35 cirrhotic A THOUSAND CHAMBER POTS livers studied by them at that time " showed a coarse multi SIR,—Dr. Munro and Mr. Williamson (July 6) pose anLlobular cirrhosis "-the latter presumably referring to post In 1957, however, Higginson et aU administrative problem : how to dispose of a thousandnecrotic scarring.
6th left intercostal artery and in four other instances from the similar branch of the 8th left intercostal artery. From the anatomical appearances it would seem that individuals possessing this type of blood-supply to the spinal cord would be very likely to suffer some degree oj cord damage should they have to undergo any operativf procedure interrupting the circulation through the lower half of the thoracic aorta or its intercostal branches.
type "
unwanted chamber pots in a mental hospital. Considering that mental hospitals always seem to possess beautifully tended gardens and that one also often finds a great many indoor plants in these hospitals, it might be an idea to use these pots for growing and propagating such plants. It is generally stated that for a plant to grow successfully it is essential for the pot in which the plant grows to have a hole at the bottom in order to allow for proper drainage, and this is of course by far the safest thing to do. I have, however, successfully grown some quite presentable specimens of tradescantia in glazed vessels containing instead of the crocked hole at the bottom a layer of pebbles and vermiculite for drain1. Ruddell, J. S.
Brit. med. J.
1956, i, 925.
Kinney, T. D., Hegsted, D. M., Finch, C. E. J. exp. Med. 1949, 90, 137. 2. Rather, L. J. Amer. J. Med. 1956, 21, 857. 3. Finch, C. A., et al. Blood, 1950, 5, 938. 4. Bothwell, T. H., van Doorn-Wittkampf, H. van W., duPreez, M. L., Alper, T. J. Lab. clin. Med. 1953, 41, 836. 5. Finch, S. C., Finch, C. A. Medicine, 1955, 34, 381. 6. Strachan, A. S. M.D. thesis Glasgow, 1929. 7. Gillman, J., Gillman, T. Arch. Path. 1945, 40, 239. 8. Gillman, J., Gillman, T. Lancet, 1948, i, 169. 9. Gillman, J., Gillman, T. Perspectives in Human Malnutrition. New York, 1951. 10. Becker, B. J. P. Leech, 1944, 15, 15. 11. Gillman, T. Ciba Colloquia on Ageing, 1957, 3, pp. 104, 188. 12. Gillman, T., Lamont, N. McE., Hathorn, M., Canham, P. A. S. Lancet, 1957, ii (in the press). 13. Wainwright, J. S. Afr. J. Lab. clin. Med. 1957, 3, 1. 14. Higginson, J., Gerritsen, T., Walker, A. R. P. Amer. J. Path. 1953, 29, 779. 15. Higginson, J., Grobbelaar, B. G., Walker, A. R. P. Ibid, 1957, 33, 29. 1.