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PANCREATITIS AND CORTISONE
828 of the eye during growth. It is unlikely, however, that a mechanical process can be entirely responsible for the exactness of adjustment required. Sorsby and his team put forward the interesting hypothesis that, just as the optic vesicle is the " organiser of the overlying ectoderm into a lens and the overlying mesoderm into sclera and cornea, so the retina (derived from the optic vesicle) may well determine the scleral, lens, and corneal sizes. A small retina will have a small overlying sclera, with, therefore, a small curved cornea and a highly curved lens. A large retina will be covered by a large sclera, and the cornea therefore must be large and flattened and the lens of large diameter and flattened. An emmetropic eye is thus conceived as the result of an orderly adjustment which takes place during growth and which is initiated by the optic vesicle and maintained by the retina. Further understanding of the nature of the refractive errors, and especially of high myopia, depends on elucidation of the hereditary transmission of the optical components of the eye. The manner of growth of the eye also requires investigation. The valuable report by Sorsby and his team includes accounts of preliminary studies on both these questions.
cortisone intravenously seem to be of value, and several workers chum life-saving results in severely shocked
PANCREATITIS AND CORTISONE ACUTE pancreatitis is usually a non-infective autolytic process precipitated by the release of activated enzymes The extent into the interstitial tissue of the gland. and severity of the autolysis seems to determine whether haemorrhagic necrosis or merely cedema ensues. Normally pancreatic enzymes are detectable in the plasmawhich suggests that a small amount of the acinar secretion is endocrine and enters the blood-stream direct, although by far the greater part is exocrine and flows into the small intestine. What upsets this relationship and initiates pancreatitis remains a mystery. Experimentally pancreatitis can be produced in several ways 1by rupture of the acini with injections under pressure down the duct, by blockage of the duct and stimulation of secretion, by damage to the pancreatic blood-supply and impairment of local nutrition, and by administration of ethionine (an analogue and anti-metabolite of the
IN the war against tonsillectomy the conservatives have so far made all the running.ll The surgeons have
"
pa,t,iei,tS.47
,
In papers which appear on earlier pages of this issue Dr. Ba.ar and Dr. Wolff describe two cases, and Dr. Marezynska-Rohowska describes a third case, of children in whom acute pancreatitis developed while they were having cortisone or corticotrophin ; and the question arises what part, if any, these hormones played in its causation. In a girl with asthma, the administration of 25 iyig. of cortisone was followed at once by pancreatitis, and Here died within five and a half hours. The other two patients had conditions which could well have been a’tiologically significant-one had extensive dermatomyositis and the other had Still’s disease, pneumonia, and smallpox. Pancreatic lesions can be produced in rabbits by <·ortisone 1° ; but pancreatitis has not previously been described as a complication of cortisone therapy in man, and there seems at present to be insufficient reason for discontinuing the assessment of cortisone treatment in acute pancreatitis provided antibiotics are given concurrently.
TONSILLECTOMY
Clinically acute pancreatitis associated with disease of the biliary tract or with acute alcoholism,2 but in neither case is the mechanism clear. Pancreatitis also arises in association with scarlet fever, otitis media, diphtheria, typhoid fever, influenza, trauma, and, of course, If the diagnosis is sure, medical treatment is directed towards relieving pain, countering shock, correcting electrolyte abnormalities, preventing suppuration, and suppressing pancreatic secretion.-1 The mortality varies from 5 to 30% and is highest in those with severe circulatory collapse. Some patients have recently been treated with cortisone or other corticosteroids,4-8 to conrbat the shock and suppress the inflammatory reaction. The shock has been ascribed to adrenal exhaustion, and also to proximity of the pancreas to the adrenals causing adrenal involvement and hence adrenal insufficiency." There is no good support for these views, although one of Bockus’s seventy-eight patients was found at necropsy to have adrenal atrophy.2 Whatever may be their action, cortisone by mouth or, when there is urgency, hydroamino-acid, methionine). is
usually
Illufnps.3
1. Grossman, M. I. Arch. intern. Med. 1955, 96, 298. 2. Bockus, H. L., Kalser, M. H., Roth, J. L. A., Bogoch, A. L., Stein, G. Ibid, p. 308. 3. Gibson, J. M., Gibson, J. M. jun. J. Pediat. 1956, 48, 486. 4. Jones, C. A. Arch. intern. Med. 1955, 96, 332. 5. Stephenson, II. E., Pfeffer, R. B., Saypol, G. M. Arch. Surg.
1952, 65, 307. Eskwith, I. S., Cacace, V. A., Sollosy, A. New Engl. J. Med. 1955, 252, 494. 7. Rogers, N. C., Wilson, A. O., Meynell, M. J., Cooke, W. T. Lancet, 1956, ii, 651. 8. Brockis, J. G., Jones, E. T. Brit. med. J. 1956, ii, 1524. 9. Jacobs, A. Lancet, 1956, ii, 733. 6.
remained silent, even though, as Fry 12 points out, over 200,000 such operations are performed annually in the United Kingdom. Crooks 13 has now written, with skill and ingenuity, in defence of the operation ; and representing, as he does, the Great Ormond Street school, he deserves close attention. Ile has selected for evaluation a series of 50 doctors’ children whose tonsils and adenoids he removed over a period of ten years. In the follow-up, he says, a skilled ohserver-the doctor-parentŇhas been constantly present to assess the result. (Skilled, certainly ; but hardly unbiased or dispassionate.) The results are presented under headings of the symptoms before operation and the effect on them of tonsillectomy. Thus, of 42 children who previously had had tonsillitis and inflamed throat, 20 were pronounced cured, 19 improved, and 3 unchanged. For all cases and symptoms, 48% were judged cured, 42% improved, and 10% unchanged or aggravated. These figures may seem encouraging ; but there was no control series, and it is fairly well known that introduction of controls shows that the operation makes no impressive difference.l4 Nor does Crooks say how many doctors’ children he declined to. operate on during the same decade. THE REFUGEES
ALTOGETHER E517 was made available to the fund for medical refugees from Hungary which we opened at the end of last year. Nearly all this money was divided between thirty doctors for such expenses as clothes, journeys, and accommodation ; but a small sum was devoted to the cost of dictionaries and of gramophone records giving elementary instruction in English. In addition, temporary homes were found for several doctors and their families with readers who had offered such help. Our Hungarian colleagues expressed warm thanks for this first-aid, reaching them as it did before they had begun to find their feet in Britain.
ACCORDING to the Civil Tables of the Registrar-General’s Statistical Review the estimated population of England and Wales for 1955 was 44,623,000. 10. Stumpf, H. H., Wilens, S. L., Somoza, C. Lab. Invest. 1956, 5, 224. 11. See Lancet, 1954, i, 208. 12. Fry, J. Brit. med. J. Jan. 19, 1957, p. 124. 13. Crooks, J. Practitioner, 1957, 178, 215. 14. McCorkle, L. P., Hodges, R. G., Badger, G. F., Dingle, J. H., S. New Engl. J. Med. 1955, 252, 1066 ; see Lancet, W. Jordan, 1955, ii, 810.
cortisone intravenously seem to be of value, and several workers chum life-saving results in severely shocked
PANCREATITIS AND CORTISONE ACUTE pancreatitis is usually a non-infective autolytic process precipitated by the release of activated enzymes The extent into the interstitial tissue of the gland. and severity of the autolysis seems to determine whether haemorrhagic necrosis or merely cedema ensues. Normally pancreatic enzymes are detectable in the plasmawhich suggests that a small amount of the acinar secretion is endocrine and enters the blood-stream direct, although by far the greater part is exocrine and flows into the small intestine. What upsets this relationship and initiates pancreatitis remains a mystery. Experimentally pancreatitis can be produced in several ways 1by rupture of the acini with injections under pressure down the duct, by blockage of the duct and stimulation of secretion, by damage to the pancreatic blood-supply and impairment of local nutrition, and by administration of ethionine (an analogue and anti-metabolite of the
IN the war against tonsillectomy the conservatives have so far made all the running.ll The surgeons have
"
pa,t,iei,tS.47
,
In papers which appear on earlier pages of this issue Dr. Ba.ar and Dr. Wolff describe two cases, and Dr. Marezynska-Rohowska describes a third case, of children in whom acute pancreatitis developed while they were having cortisone or corticotrophin ; and the question arises what part, if any, these hormones played in its causation. In a girl with asthma, the administration of 25 iyig. of cortisone was followed at once by pancreatitis, and Here died within five and a half hours. The other two patients had conditions which could well have been a’tiologically significant-one had extensive dermatomyositis and the other had Still’s disease, pneumonia, and smallpox. Pancreatic lesions can be produced in rabbits by <·ortisone 1° ; but pancreatitis has not previously been described as a complication of cortisone therapy in man, and there seems at present to be insufficient reason for discontinuing the assessment of cortisone treatment in acute pancreatitis provided antibiotics are given concurrently.
TONSILLECTOMY
Clinically acute pancreatitis associated with disease of the biliary tract or with acute alcoholism,2 but in neither case is the mechanism clear. Pancreatitis also arises in association with scarlet fever, otitis media, diphtheria, typhoid fever, influenza, trauma, and, of course, If the diagnosis is sure, medical treatment is directed towards relieving pain, countering shock, correcting electrolyte abnormalities, preventing suppuration, and suppressing pancreatic secretion.-1 The mortality varies from 5 to 30% and is highest in those with severe circulatory collapse. Some patients have recently been treated with cortisone or other corticosteroids,4-8 to conrbat the shock and suppress the inflammatory reaction. The shock has been ascribed to adrenal exhaustion, and also to proximity of the pancreas to the adrenals causing adrenal involvement and hence adrenal insufficiency." There is no good support for these views, although one of Bockus’s seventy-eight patients was found at necropsy to have adrenal atrophy.2 Whatever may be their action, cortisone by mouth or, when there is urgency, hydroamino-acid, methionine). is
usually
Illufnps.3
1. Grossman, M. I. Arch. intern. Med. 1955, 96, 298. 2. Bockus, H. L., Kalser, M. H., Roth, J. L. A., Bogoch, A. L., Stein, G. Ibid, p. 308. 3. Gibson, J. M., Gibson, J. M. jun. J. Pediat. 1956, 48, 486. 4. Jones, C. A. Arch. intern. Med. 1955, 96, 332. 5. Stephenson, II. E., Pfeffer, R. B., Saypol, G. M. Arch. Surg.
1952, 65, 307. Eskwith, I. S., Cacace, V. A., Sollosy, A. New Engl. J. Med. 1955, 252, 494. 7. Rogers, N. C., Wilson, A. O., Meynell, M. J., Cooke, W. T. Lancet, 1956, ii, 651. 8. Brockis, J. G., Jones, E. T. Brit. med. J. 1956, ii, 1524. 9. Jacobs, A. Lancet, 1956, ii, 733. 6.
remained silent, even though, as Fry 12 points out, over 200,000 such operations are performed annually in the United Kingdom. Crooks 13 has now written, with skill and ingenuity, in defence of the operation ; and representing, as he does, the Great Ormond Street school, he deserves close attention. Ile has selected for evaluation a series of 50 doctors’ children whose tonsils and adenoids he removed over a period of ten years. In the follow-up, he says, a skilled ohserver-the doctor-parentŇhas been constantly present to assess the result. (Skilled, certainly ; but hardly unbiased or dispassionate.) The results are presented under headings of the symptoms before operation and the effect on them of tonsillectomy. Thus, of 42 children who previously had had tonsillitis and inflamed throat, 20 were pronounced cured, 19 improved, and 3 unchanged. For all cases and symptoms, 48% were judged cured, 42% improved, and 10% unchanged or aggravated. These figures may seem encouraging ; but there was no control series, and it is fairly well known that introduction of controls shows that the operation makes no impressive difference.l4 Nor does Crooks say how many doctors’ children he declined to. operate on during the same decade. THE REFUGEES
ALTOGETHER E517 was made available to the fund for medical refugees from Hungary which we opened at the end of last year. Nearly all this money was divided between thirty doctors for such expenses as clothes, journeys, and accommodation ; but a small sum was devoted to the cost of dictionaries and of gramophone records giving elementary instruction in English. In addition, temporary homes were found for several doctors and their families with readers who had offered such help. Our Hungarian colleagues expressed warm thanks for this first-aid, reaching them as it did before they had begun to find their feet in Britain.
ACCORDING to the Civil Tables of the Registrar-General’s Statistical Review the estimated population of England and Wales for 1955 was 44,623,000. 10. Stumpf, H. H., Wilens, S. L., Somoza, C. Lab. Invest. 1956, 5, 224. 11. See Lancet, 1954, i, 208. 12. Fry, J. Brit. med. J. Jan. 19, 1957, p. 124. 13. Crooks, J. Practitioner, 1957, 178, 215. 14. McCorkle, L. P., Hodges, R. G., Badger, G. F., Dingle, J. H., S. New Engl. J. Med. 1955, 252, 1066 ; see Lancet, W. Jordan, 1955, ii, 810.