PROPHYLACTIC PORTACAVAL SHUNT

515

the district. This highly imaginative scheme, in which there is intimate integration of preventive and curative services, is in striking contrast to the type of teaching of public health that still goes on in many of the Mediterranean countries. FŒTAL ELECTROCARDIOGRAPHY

FOR many years it has been the hope that new developin foetal electrocardiography would provide reliable and precise information about the condition of the foetus in utero; but auscultation of the foetal heart, with its obvious limitations, remains the chief method used by midwives and doctors to check the wellbeing of the child. In spite of technical advances, foetal electrocardiography is still largely a research procedure that has little effect on clinical practice. Even with the most advanced and refined techniques, it is hard to obtain apparatus consistent and clear recordings of the full complex using abdominal leads; usually only the initial ventricular deflections or QRS waves are shown. Better results are achieved by direct application of electrodes to the foetal head, 1-3 but this can be done only when the cervix is dilated and the membranes ruptured. An important drawback in present abdominal techniques is the poor signal-to-noise ratio even though high-quality preamplifiers of great sensitivity are used.145 in practical terms, this means that the baseline of the complex is obscured by background noise, and subtle alterations in the configuration of the foetal electrocardiogram can neither be observed nor be interpreted. The noise levels can be high enough to mask p and T waves and s-T segment changes.4 These deficiencies have greatly limited the value of foetal electrocardiography. But the problem of separating repetitive signals from background noise is not insuperable and has been tackled successfully in the physical and (to a lesser degree) the biological sciences by means of averaging techniques using a digital computer.46 When the interval is constant the signals add in linear fashion and the average of 20 or 30 is obtained. The background noise, varying from- one moment to another, is largely eradicated. Unfortunately this technique cannot be applied directly to foetal electrocardiography, since there is a variable interval between heart-beats. Hon and Lee45 have recently shown how this difficulty can be overcome, and they describe a technique for preparing foetal electrocardiographs for this type of computation. They have studied various methods of placing a trigger pulse in front of each complex so that the interval between the trigger and the peak of the following R wave is constant and linear addition of the complexes is possible. Their technique uses a magnetic tape recorder and a small digital computer, and their averaging method applies equally well to electrocardiograms obtained vaginally or abdominally. By averaging 20 or 30 complexes, Hon and Lee obtain striking improvement in the signalto-noise ratio and a foetal E.C.G. in which the baseline changes can be seen clearly. In their technique the number of complexes to be averaged is critical: too few will give no significant improvement in the signal-tonoise ratio; too many will obscure short-lived variations which will be averaged out. According to Hon and Lee,5 alterations in configuration usually persist for more than 20 or 30 complexes,

but this point requires further careful study. Provided this supposition is correct, their method of averaging a series of fcetal heart complexes represents an important advance in technique, giving a consistent and clear record of the finer points in the foetal E.c.G., and these in turn can be related to the clinical circumstances. Further on work will this be awaited with interest. reports

ments

1. 2.

3. 4. 5. 6.

Smyth, C. N., Farrow, J. L. Brit. med. J. 1958, ii, 1005. Hon, E. H., Hess, O. W. Amer. J. Obstet. Gynec. 1960, 79, 1012. Hon, E. H. ibid. 1963, 86, 772. Hon, E. H., Lee, S. T. ibid. 1963, 87, 1086. Hon, E. H., Lee, S. T. Med. electron. biol. Engng, 1964, 2, 71. Brazier, M. Ann. N.Y. Acad. Sci. 1961, 92, 1054.

PROPHYLACTIC

PORTACAVAL

SHUNT

A COOPERATIVE investigation1 carried out in six Boston hospitals aimed at deciding whether or not a prophylactic portacaval anastomosis was justified in cirrhotic patients who had oesophageal varices and who had not yet had a haemorrhage. And this is indeed a problem which is in urgent need of solution. The risks of haemorrhage in this

condition are well known. Ratnoff and Patek2 showed in 1942 that no more than 30% of cirrhotic patients survived one year from their first hxmorrhage; and Taylor and Jontz3 and the Boston Inter-Hospital Liver Group themselves have shown that this figure has changed little since. But to do a portacaval anastomosis on a patient who has not bled is a formidable undertaking and must be justified by an improvement in results. During the period of study, 1959-61, 471 cases of cirrhosis were seen at the six Boston hospitals; and 288 had not bled. From these only 50 were selected for the test: they had all survived for two to three months since admission and they were fit enough to undergo a portacaval anastomosis if they were chosen for operation; they had unequivocal evidence of oesophageal varices; and there was no reluctance to the operation on the part of the patient, his doctor, or the surgeon. All these 50 patients were fully assessed and found to be comparable; and after random selection, 28 had prophylactic portacaval anastomoses and 22 did not. All but 1 in each group had drunk alcohol to excess; all but 5 in each had had ascites; and tolerance to protein in each group was comparable. Results were assessed every six months and the points noted included: general appearance of patient, presence of ascites, size of liver and spleen, hoemoglobin, serumalbumin, serum-bilirubin, prothrombin-time, tolerance to dietary protein, return to work, hxmorrhage, and recurrence of drinking. After three years, the position was as follows:

patients operated on.-9 dead [4 " operative " deaths, hepatocellular failure (2 patients continued to drink heavily), 1 incidental death, and 1 death from an unknown cause]. No patient had a haemorrhage. The threeyear survival-rate is apparently about 68%. 22 not operated on.-8 dead [4 died of massive hxmorrhage (3 from varices and 1 from duodenal ulcer), 1 of hepatocellular failure, 1 of renal failure, 2 of unknown causes]. 2 other patients had haemorrhages from varices and portacaval anastomoses were successfully constructed. 1 of these patients later died of haemorrhage from a duodenal ulcer. Here the three-year survival-rate seems to be 64%. 28

3 late deaths from

might be expected, the state of the varices was distinctly better in the surgically treated group: in only 2 of the 19 survivors did they remain apparent, compared with 11of the 14 survivors in the non-surgical group. Hepatic pre-coma was a problem in 4 of the 19 surgical survivors and in only 1 of the control group. Ascites persisted in 2 of the controls and in 1 of the surgical group (who continues to drink heavily). 6 surgical and 8 nonAs

Garceau, A. J., Donaldson, R. M., O’Hara, E. T., Callow, A. D., Muench, H., Chalmers, T. C. New Engl. J. Med. 1964, 270, 496. 2. Ratnoff, O. D., Patek, A. J., Jr. Medicine, Baltimore, 1942, 21, 207. 3. Taylor, F. W., Jontz, J. G. Arch. Surg. 1959, 78, 786. 1.

516

periodical admission to hospital may be necessary but is in each group have returned to full housework. only incidental. In one Moscow hospital, for instance, The results in the two groups are thus reasonably there are each year about three admissions per bed, or nine similar. They were naturally very much better than the times as many as in a comparable American institution; results in those " not selected for study ", in whom the and of these, only 5 % or so are first admissions. Readmisthree-year survival-rate was no more than about 16%: sion, however, is a sign not so much of failed therapy as of those not selected included all patients who had failed to what is being attempted. reach a reasonable state of health at the end of the first In the Soviet psychiatric service outpatient treatment is three months of treatment for cirrhosis and all patients the first line of defence. It is provided at district clinics who refused operation or who were judged unfit for where each full-time psychiatrist serves a population of about 16,000. Care is comprehensive. The psychiatrist is surgery. The Boston workers recognise that the series is too small to be of decisive value; and indeed it responsible, in the first place, for diagnosis; he must promay not be possible to give a three-year follow-up of vide a variety of treatments, including, for instance, drug patients selected in 1959-61 in an article published therapy, psychotherapy, and speech therapy; and he it is in March, 1964. Many people would put the who arranges for hospital treatment where appropriate. operative risk of portacaval anastomosis done during or The clinics themselves have a few beds which can be used after the first haemorrhage at 5% or less.4 If the operative for brief or emergency admissions. They have, besides, where patients can be employed mortality in the group of cirrhotics had been nearer their attached this figure, the survival-rates in those operated on might be according to their abilities-but on real work rather than materially better than in those not so treated. Further, occupational therapy. (Not surprisingly, since, according to Marx, labour is the primary activity of man.) Day 5 of the 22 in the non-operation group had haemorrhage from varices during the period under review, 3 dying of hospitals are common too. Further, and partly for ideohaemorrhage and 2 having portacaval anastomoses- logical reasons, Soviet psychiatric care extends into the which surely counts in favour of doing the operation in social and material environment of the patient. Each clinic

surgical patients have returned to full work; and 2 women

workshops

good time. The authors’ conclusion is that " survival is improved dramatically by selection for the study, but has not been influenced by choice of treatment thus far "-which is merely to say that good-risk cirrhotic patients survive longer than poor-risk cirrhotics, whether they have a shunt or not. This analysis is a worthy effort which should be pursued further; but it has not so far provided enough evidence for judging the value of a prophylactic shunt.

PSYCHIATRIC CARE IN THE SOVIET UNION

To many Americans it would come as a surprise to see a comparative survey which suggests that the mendisturbed tally patient may get more care and attention in the Soviet Union than in the United States. Reviewing the attitudes current in the two countries, Field5 concludes that, for Russian psychiatry, past economic stringency has been a blessing in disguise. Comprehensive and comparable figures are hard to come by, but there is no reason to suppose that the prevalence or nature of mental illness differs significantly between the two countries. The wealth of psychiatrists in the United States-an average of 6-4 per 100,000 population-is well known. But the Soviet Union has even more-about 8-4 per 100,000-and is increasing their number faster. Provision of psychiatric beds, on the other hand, is more liberal in the United States: every other hospital bed, or four beds per 1000 population, is used by a mental patient. The comparable Soviet figures are one bed in eight, or about one per 1000 people. This the Russians recognise as inadequate, and they aim to increase provision to about two beds per 1000 within the next few years. But the shortage of hospital accommodation has had some advantages. The staff/patient ratio is high, generally 1/1(compared with 1/4 in most American public mental hospitals), and such beds as there are must be used intensively. A policy of vigorous treatment and short stays has been adopted in the Soviet Union with the aim of maintaining disturbed patients in the community wherever possible: recent

4. 5.

Linton, R. R., Diseases of the Liver (edited by L. Schiff); p. 275. Philadelphia, 1963. Field, M. G. Rev. Soviet med. Sciences, 1964, 1, 1.

maintains staff ready to help patients by finding them a less crowded place in which to live, by relieving family tensions, by applying for financial assistance, by giving vocational guidance, or by arranging for legal assistance, expert testimony, or certification of disability. Finally, every psychiatrist is required to spend at least four hours a month in making some sort of contribution to the health education of the public. Field points out that the primacy of outpatient psychiatry was forced on the Russians at the start by the necessity of providing a psychiatric service with virtually no materials. The results have been happy. Disturbed patients cannot, as in the United States, be isolated from the community in large and impersonal institutions where they receive next to no treatment, are given no constructive occupation, and merely become increasingly unfit for society. Whether psychoneurological clinics are commonplace throughout the Soviet Union or are isolated showpieces peculiar to the larger cities, they are in line with the most advanced psychiatric thinking in the West and demonstrate that-at least in a country that is still largely rural-community care can be made to work.

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