- Email: [email protected]
SHOULD BIBLIOGRAPHIES GIVE TITLES OF PAPERS?
157
that relatively small quantities of vitamin B12 were absorbed. This too can be taken as evidence against the absorption by simple diffusion of unaltered vitamin-B12peptides, since the amounts of vitamin absorbed were very small fractions of the total amounts administered. We have, of course, yet to see the proof that Dr. Heathand Dr. Mooney were actually administering a vitamin-B12-peptide and not a mixture of the free vitamin and a peptide. In our opinion, the absorptions they obtained might well be expected from the administration in similar dosage of vitamin B12 alone, and control investigations are badlv needed. cote
Department of Pathology, King’s College, University of Durham, Royal Victoria Infirmary, Newcastle upon Tyne.
C. GREEN A. L. LATNER.
DILUTION ANÆMIA "
physiological anaemia of pregnancy " is due to an increased plasma volume.1-4 Likewise, in chronic myelogenous leukxmia increased plasma-volumes have been found. 56 SiR,ňThe
It is conceivable that low concentrations of haemoglobin (Hb) in the peripheral blood may be explained as dilution effects in other states. Such patients may have a normal amount of total body hxmoglobin (THb) (i.e., 1-12 g. per kg. in males and 0-86 g. per kg. in females) and an increased total blood-volume. FOUR CASES ILLUSTRATING DILUTION ANEMIA
draw attention to these states in the hope that bloodtransfusions, which are probably unnecessary in simple hypervolxmia, and which are expensive and not without danger, may be avoided. A more thorough examination of dilution anxmias is in to
DreDaration. Departments of Internal Medicine and Clinical Physiology, Karolinska Institutet, Serafimerlasarettet, Stockholm.
P. G. REIZENSTEIN.
SHOULD BIBLIOGRAPHIES GIVE TITLES OF PAPERS?
SiR,ňThe bibliography of American medical papers is much more valuable than that of British papers, because of the almost invariable American practice of giving titles. Is it not time that we in this country adopted the American practice, and will not you, Sir, pioneer this advance ? The Middlesex Hospital. London, W.1.
DAVID H. PATEY.
*** We agree with Mr. Patey that there are advantages giving titles in references; but the extra space needed is, we think, too great to justify making this change in The Lancet. Under our present system we use a weekly
in
average of between
one and two columns for references to To include titles of papers would at least double this consumption. To compensate for this, we should have to exclude an article of perhaps 1000-1200 words.-ED. L.
original articles.
PHYSICAL CHANGES IN THE PROLAPSED DISC
SIR,-Some of the questions raised in your annotation1 are answered in work already published by US.2-10 This was recently summarised by us at the March meeting of the Comparative Medicine Section of the Royal Society of Medicine.1O To reiterate briefly: the tendency to disc prolapse depends upon the intra-disc tension and the structural
state
of the annulus fibrosus and the nucleus
pulposus.
*
This case has been reported previously. 7-9 Hb, THb, and blood-volume (estimated same day) in 4 patients. Hb 100% for males = 15’4 g. per 100 ml.; for females 13,9 g. THb determined by the alveolar carbon monoxide method 10; normal blood-volume =normal THb-normal Hb concentration.
It is questionable whether it is possible or even desirable to increase the THb above the normal amount in such cases, in an effort to make the haemoglobin concentration normal, by giving blood-transfusions; and it does not seem to be known whether adequate circulatory function or even the feeling of wellbeing is more dependent on the THb (i.e., total red-cell volume) or on the hemoglobin concentration. Until further information is available it seems reasonable to regard patients with normal THb as healthy from the point of view of anaemia. But cases of dilution anaemia may not be diagnosed as such and may be treated as having genuine anaemia. Because theansemia " is refractory to other treatment, these patients are sometimes given numerous blood-transfusions (as well as parenteral iron and liver or vitamin B12) over long periods of time (see accompanying table). The purpose of this letter is "
"
Dieckmann, W. I., Wegner, C. R. Arch. intern. Med. 1918, 53, 596. Thomsson, K. I., Hirschheimer, A., Gibson, I. G., Jr., Evans, W. A. Amer. J. Obstet. Gynec. 1938, 36, 48. 3. Bethell, F. H., Gardiner, S. H., McKennon, F. Ann. intern. Med. 1939, 13, 91. 4. Gemzell, C. A., Robbe, Hj., Ström, G. Acta obstet. gynec. scand. 1957, 36, 93. 5. Forkner, C. E. in Leukemia and Allied Disorders. New York, 1957. 6. Berlin, N. J., Lawrence, J. H., Gartland, I. J. Lab. clin. Med. 1950, 36,
1. 2.
435. 7. 8. 9. 10.
Luft, R., Sjögren, B. Nord. Med. 1948, 40, 1764 (case 1). Luft, R., Sjogren, B. Acta endocr., Copenhagen 1949, 2, 287 (case 4). Loft, R., von Euler, U. S. J. clin. Invest. 1953, 32, 1065 (case 1). Sjostrand, T. Acta physiol. scand. 1948, 16, 201 ,211.
Increase of intra-disc tension possibly arises as a result of the " triggering " of a sequence of changes probably by an endocrine factor whereby, amongst other possible changes, depolymerisation of the polysaccharides of the nucleus leads to increased power of fluid absorption and thus increased fluid absorption with resultant rise in intra-disc pressure. As the depolymerised molecules are removed there is a return to the status quo with relief of symptoms. With each episode of symptoms, this process is repeated so that the total polysaccharide content is reduced, producing a degenerated, desiccated disc. A stage will be ultimately reached whereby the concentration of the polysaccharide and power of fluid absorption are so reduced that prolapse cannot occur. Our intra-disc pressure measurements showed fluid absorption to produce the highest pressures in the 35-55 age-group, which parallels the incidence of disc prolapse. Our X-ray crystallographic studies have shown that beyond the age of 40 the reduction of polysaccharide, though relative, is associated with precipitation of the collagen. Such a process causes the incompressible gel structure of the nucleus pulposus to change to a fibrosed mass incapable of uniform transmission of stress. This uneven dissipation of stress causes gradual attrition of the annulus. With increasing age, precipitation of the collagen in the annulus results in decreased elasticity. We 1. Lancet, 1958, i, 1214. 2. Naylor, A. Ann. R. Coll. Surg. Engl. 1951, 9, 158. 3. Naylor, A., Smare, D. L. Brit. med. J. 1953, ii, 975. 4. Happey, F., McCrae, T. P., Naylor, A. Nature and Structure of
Collagen, Faraday Society, London, 1953. 5. Naylor, A., Happey, F., McCrae, T. P. Brit. med. J. 1954, ii, 570. 6. Bush, H. D., Horton, W. G., Smare, D. L., Naylor, A. ibid. 1956, ii, 81. 7. Happey, F., Horton, W. G., McCrae, T. P., Naylor, A. Nature, Lond. 1955, 175, 1032. 8. Hall, D. A., Lloyd, P. F., Happey, F., Horton, W. G., Naylor, A.
ibid. 1957, 179, 1078. 9. Bernardi, G., Happey, F., Naylor, A. ibid. 1957, 10. Naylor, A. Proc. R. Soc. Med. (in the press).
180, 1341.
that relatively small quantities of vitamin B12 were absorbed. This too can be taken as evidence against the absorption by simple diffusion of unaltered vitamin-B12peptides, since the amounts of vitamin absorbed were very small fractions of the total amounts administered. We have, of course, yet to see the proof that Dr. Heathand Dr. Mooney were actually administering a vitamin-B12-peptide and not a mixture of the free vitamin and a peptide. In our opinion, the absorptions they obtained might well be expected from the administration in similar dosage of vitamin B12 alone, and control investigations are badlv needed. cote
Department of Pathology, King’s College, University of Durham, Royal Victoria Infirmary, Newcastle upon Tyne.
C. GREEN A. L. LATNER.
DILUTION ANÆMIA "
physiological anaemia of pregnancy " is due to an increased plasma volume.1-4 Likewise, in chronic myelogenous leukxmia increased plasma-volumes have been found. 56 SiR,ňThe
It is conceivable that low concentrations of haemoglobin (Hb) in the peripheral blood may be explained as dilution effects in other states. Such patients may have a normal amount of total body hxmoglobin (THb) (i.e., 1-12 g. per kg. in males and 0-86 g. per kg. in females) and an increased total blood-volume. FOUR CASES ILLUSTRATING DILUTION ANEMIA
draw attention to these states in the hope that bloodtransfusions, which are probably unnecessary in simple hypervolxmia, and which are expensive and not without danger, may be avoided. A more thorough examination of dilution anxmias is in to
DreDaration. Departments of Internal Medicine and Clinical Physiology, Karolinska Institutet, Serafimerlasarettet, Stockholm.
P. G. REIZENSTEIN.
SHOULD BIBLIOGRAPHIES GIVE TITLES OF PAPERS?
SiR,ňThe bibliography of American medical papers is much more valuable than that of British papers, because of the almost invariable American practice of giving titles. Is it not time that we in this country adopted the American practice, and will not you, Sir, pioneer this advance ? The Middlesex Hospital. London, W.1.
DAVID H. PATEY.
*** We agree with Mr. Patey that there are advantages giving titles in references; but the extra space needed is, we think, too great to justify making this change in The Lancet. Under our present system we use a weekly
in
average of between
one and two columns for references to To include titles of papers would at least double this consumption. To compensate for this, we should have to exclude an article of perhaps 1000-1200 words.-ED. L.
original articles.
PHYSICAL CHANGES IN THE PROLAPSED DISC
SIR,-Some of the questions raised in your annotation1 are answered in work already published by US.2-10 This was recently summarised by us at the March meeting of the Comparative Medicine Section of the Royal Society of Medicine.1O To reiterate briefly: the tendency to disc prolapse depends upon the intra-disc tension and the structural
state
of the annulus fibrosus and the nucleus
pulposus.
*
This case has been reported previously. 7-9 Hb, THb, and blood-volume (estimated same day) in 4 patients. Hb 100% for males = 15’4 g. per 100 ml.; for females 13,9 g. THb determined by the alveolar carbon monoxide method 10; normal blood-volume =normal THb-normal Hb concentration.
It is questionable whether it is possible or even desirable to increase the THb above the normal amount in such cases, in an effort to make the haemoglobin concentration normal, by giving blood-transfusions; and it does not seem to be known whether adequate circulatory function or even the feeling of wellbeing is more dependent on the THb (i.e., total red-cell volume) or on the hemoglobin concentration. Until further information is available it seems reasonable to regard patients with normal THb as healthy from the point of view of anaemia. But cases of dilution anaemia may not be diagnosed as such and may be treated as having genuine anaemia. Because theansemia " is refractory to other treatment, these patients are sometimes given numerous blood-transfusions (as well as parenteral iron and liver or vitamin B12) over long periods of time (see accompanying table). The purpose of this letter is "
"
Dieckmann, W. I., Wegner, C. R. Arch. intern. Med. 1918, 53, 596. Thomsson, K. I., Hirschheimer, A., Gibson, I. G., Jr., Evans, W. A. Amer. J. Obstet. Gynec. 1938, 36, 48. 3. Bethell, F. H., Gardiner, S. H., McKennon, F. Ann. intern. Med. 1939, 13, 91. 4. Gemzell, C. A., Robbe, Hj., Ström, G. Acta obstet. gynec. scand. 1957, 36, 93. 5. Forkner, C. E. in Leukemia and Allied Disorders. New York, 1957. 6. Berlin, N. J., Lawrence, J. H., Gartland, I. J. Lab. clin. Med. 1950, 36,
1. 2.
435. 7. 8. 9. 10.
Luft, R., Sjögren, B. Nord. Med. 1948, 40, 1764 (case 1). Luft, R., Sjogren, B. Acta endocr., Copenhagen 1949, 2, 287 (case 4). Loft, R., von Euler, U. S. J. clin. Invest. 1953, 32, 1065 (case 1). Sjostrand, T. Acta physiol. scand. 1948, 16, 201 ,211.
Increase of intra-disc tension possibly arises as a result of the " triggering " of a sequence of changes probably by an endocrine factor whereby, amongst other possible changes, depolymerisation of the polysaccharides of the nucleus leads to increased power of fluid absorption and thus increased fluid absorption with resultant rise in intra-disc pressure. As the depolymerised molecules are removed there is a return to the status quo with relief of symptoms. With each episode of symptoms, this process is repeated so that the total polysaccharide content is reduced, producing a degenerated, desiccated disc. A stage will be ultimately reached whereby the concentration of the polysaccharide and power of fluid absorption are so reduced that prolapse cannot occur. Our intra-disc pressure measurements showed fluid absorption to produce the highest pressures in the 35-55 age-group, which parallels the incidence of disc prolapse. Our X-ray crystallographic studies have shown that beyond the age of 40 the reduction of polysaccharide, though relative, is associated with precipitation of the collagen. Such a process causes the incompressible gel structure of the nucleus pulposus to change to a fibrosed mass incapable of uniform transmission of stress. This uneven dissipation of stress causes gradual attrition of the annulus. With increasing age, precipitation of the collagen in the annulus results in decreased elasticity. We 1. Lancet, 1958, i, 1214. 2. Naylor, A. Ann. R. Coll. Surg. Engl. 1951, 9, 158. 3. Naylor, A., Smare, D. L. Brit. med. J. 1953, ii, 975. 4. Happey, F., McCrae, T. P., Naylor, A. Nature and Structure of
Collagen, Faraday Society, London, 1953. 5. Naylor, A., Happey, F., McCrae, T. P. Brit. med. J. 1954, ii, 570. 6. Bush, H. D., Horton, W. G., Smare, D. L., Naylor, A. ibid. 1956, ii, 81. 7. Happey, F., Horton, W. G., McCrae, T. P., Naylor, A. Nature, Lond. 1955, 175, 1032. 8. Hall, D. A., Lloyd, P. F., Happey, F., Horton, W. G., Naylor, A.
ibid. 1957, 179, 1078. 9. Bernardi, G., Happey, F., Naylor, A. ibid. 1957, 10. Naylor, A. Proc. R. Soc. Med. (in the press).
180, 1341.