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STATUS THYMOLYMPHATICUS
612
possibly be applicable to sputum examinabut tion, they will probably need even more experience and be even more time-consuming than those already in use. A DISEASE OF CIVILISATION? methods may
Two American papers 12 recount an odd story which will interest the nutritionist. During the past two or three years quite a number of infants 2-4 months old have been admitted to hospitals up and down the United States because of convulsions for which there was no apparent cause. A comprehensive "work-up" yielded consistently normal results.2 The investigators then turned their attention to the infants’ environment, and found that before admission to hospital all had been receiving the same proprietary infant food, consisting of defatted cow’s milk, animal fats, vegetable fats, iron, and vitamins. This was then prepared according to the formula and was analysed ; and it proved deficient in vitamin By, 1 litre of the formula containing less than 60 g. of pyridoxine hydrochloride. Deficiency of this vitamin was already known to cause convulsions in man,34 and so the problem was solved. Pyridoxine was administered to the babies, and there were no more fits. The vitamin has now been added to the proprietary milk.
STATUS THYMOLYMPHATICUS IT is always agreeable to assist in the obsequies of a medical myth, particularly if one is sure that it,is dead. Willing hands are again trying to lay status thymolymphaticus to rest.5-7 The concept of lymphoid and thymic hyperplasia accompanied by a liability to sudden death came to the fore in Vienna at the end of the last century. Though backed by no convincing pathological evidence, the idea gained ground, and ten years later it began to appear in British textbooks. In 1911 a separate column was first allotted to diseases of the thymus in the annual report of the Registrar-General. Since then many attacks have been made on it, the most authoritative being that of a joint committee of the Medical Research Council and the Pathological Society of Great Britain, which in 1931 after a careful study of 680 necropsies, that reported, " there is no evidence that the so-called status thymolymphaticus has any existence as a pathological entity."7 Littleton et al.6 have examined one of the five hypotheses accounting for death in " status thymolymphaticus "-namely, that the thymus can compress the trachea In careful anatomical and and lead to suffocation. found no evidence suggesting studies they radiographic that this might happen even if the gland were enlarged In the young, radiography of the or abnormally placed. thymus can be very difficult ; the range of normal is wide, and there is no absolute measure of enlargement. The vascular shadows in the infant’s mediastinum vary greatly in shape and width, especially if the film is taken in expiration or while the child is screaming (a glance at the jaw may help to settle this point). Screening is always advisable in the doubtful case, but lateral views of the chest are seldom helpful. It has long been uncertain whether a normal thymus can be seen, but it is now generally agreed that the small triangular projections from the mediastinum-the so-called sail shadows-can represent the edges of a normal thymus. Sometimes slight scoliosis or a mediastinal shift, secondary to collapse or agenesis of lung, may possibly displace the gland and cause its profile to appear. 1. Molony, C. J., Parmelee, A. H. J. Amer. med. Ass. 405. 2. Coursin, D. B. Ibid, p. 406. 3. Report of the Council on Pharmacy and Chemistry.
1954, 154, Ibid, 1951,
147, 322. 4. Snyderman, S. E., Carretero, R., Holt, L. E. J. clin. Nutr. 1953, 1, 200. 5. Dodwell, H. B. Brit. med. J. Jan. 16, 1954, p. 149. 6. Littleton, J. T., Motsay, D. S., Perry, S. P. Amer. J. Dis. Child. 1953, 86, 705. 7. See Lancet, 1931, i, 593.
Until these
points were recognised, thymic enlargement commonly diagnosed, and radiology was thus on the side of those who wish to keep status thymolym. phaticus alive or at least unburied. Among these, Ucko * has lately suggested that thymic and lymphoid hyper. plasia reflects pituitary-adrenocortical deficiency; and Neale9 remarks that in a morbid-anatomical study of cases of status thymolymphaticus he found that the adrenal glands were commonly small. Neale suggests that a skilled team should investigate the adrenocortical reserve of patients with suspected status thymolymphaticus. So
was
the would-be interrers
once more
find their way barred.
BIOPSY OF THE LIVER THE present method of aspiration biopsy of the liver was introduced by Iversen and Roholm 10 in 1939. Zamcheck and his colleagues 11 12have now appraised this ASPIRATION
investigation. Among 20,016 patients who underwent aspiration biopsy the mortality was 0-17%; and excluding cases which by today’s criteria would not be submitted to it the mortality was 0-085%. Schiff13 and Haex 14 had not a single fatality in 2800 cases. The principal risks are haemorrhage due to tearing of the liver, and bile peritonitis from perforation of a distended intra. hepatic duct. This second complication has been recorded only in association with extrahepatic biliary obstruction; so the signs of bile peritonitis after aspiration biopsy are a strong indication for immediate laparotomy. An impressive list of the diseases in which this investigation has been essential for diagnosis in individual cases includes amyloidosis ; Gaucher’s disease; Kinnier Wilson’s disease ; hsemochromatosis ; various grantdomatous lesions, including tuberculosis, leprosy, brucel. losis, and sarcoidosis; fungal infections; infectious mononucleosis ; leptospirosis ; toxic hepatitis ; lymphomas ; leukaemia, ; and many of the parasitic infections, such as kala-azar, hydatid disease, and schistosomiasis. von Falkenhausen et al.15 suggest that liver biopsy be considered in all obscure cases where a definite diagnosis has not been reached by other methods. Biopsy has revealed the uncertainty of clinical diagnosis of liver disorders even when based on a complete history, physical examination, general laboratory and liver-function tests, and radiographic examination. Thus Berk and Shay" found that in 12 out of 45 cases the diagnosis had to be changed as a result of the biopsy ; and Moyer and Worl11 found that almost a third of their patients diagnosed clinically as having cirrhosis in fact had only fatty liver without fibrosis. Perhaps the greatest diagnostic value of aspiration biopsy is in differentiating between " medical " and "surgical " jaundice, since "surgical" jaundice requires urgent operation, which in " medical" jaundice is strongly contra-indicated and is associated with a high mortality. Although usually this differentiation is fairly easy, in about 15% of cases an exact diagnosis is impossible without histological examination. With few exceptions this establishes the difference, especially in the early stages. Procrastination is to be avoided since as time goes on the characteristic parenchymal changes of hepatitis tend to be obscured and the danger of biopsy in obstructive jaundice increases. Against the potential dangers of needle biopsy have to be set its advantages. In 46 of 6062 necropsies at the Mallory Institute of Pathology 18 unsuspected gall-stone obstruction of the common bile-duct was found, and in 8. 9. 10. 11. 12. 13. 14. 15.
Ucko, H. Brit. med. J. Feb. 13, 1954, p. 398. Neale, A. V. Ibid, March 6, 1954, p. 582. Iversen, P., Roholm, K. Acta med. scand. 1939, 102, 1. Zamcheck, N., Sidman, R. L. New. Engl. J. Med. 1953, 249, 1020. Zamcheck, N., Klausenstock, O. Ibid, p. 1062. Schiff, L. Cited by N. Zamcheck and R. L. Sidman (footnote 11). Haex, A. J. C. Ned. Tijdschr. Geneesk. 1950, 94, 3072. von Falkenhausen, M., Konig, J., Nagel, H. H. Dtsch. med. Wschr. 1948, 73, 88. 16. Berk, J. E., Shay, H. J. Amer. med. Ass. 1952, 148, 109. 17. Moyer, J. H., Worl, O. A. Amer. J. med. Sci. 1951, 221, 28. 18. Klausenstock, O., Zamcheck, N., Robbins, S. Cited by N. Zamcheck and R. L. Sidman (footnote 11).
possibly be applicable to sputum examinabut tion, they will probably need even more experience and be even more time-consuming than those already in use. A DISEASE OF CIVILISATION? methods may
Two American papers 12 recount an odd story which will interest the nutritionist. During the past two or three years quite a number of infants 2-4 months old have been admitted to hospitals up and down the United States because of convulsions for which there was no apparent cause. A comprehensive "work-up" yielded consistently normal results.2 The investigators then turned their attention to the infants’ environment, and found that before admission to hospital all had been receiving the same proprietary infant food, consisting of defatted cow’s milk, animal fats, vegetable fats, iron, and vitamins. This was then prepared according to the formula and was analysed ; and it proved deficient in vitamin By, 1 litre of the formula containing less than 60 g. of pyridoxine hydrochloride. Deficiency of this vitamin was already known to cause convulsions in man,34 and so the problem was solved. Pyridoxine was administered to the babies, and there were no more fits. The vitamin has now been added to the proprietary milk.
STATUS THYMOLYMPHATICUS IT is always agreeable to assist in the obsequies of a medical myth, particularly if one is sure that it,is dead. Willing hands are again trying to lay status thymolymphaticus to rest.5-7 The concept of lymphoid and thymic hyperplasia accompanied by a liability to sudden death came to the fore in Vienna at the end of the last century. Though backed by no convincing pathological evidence, the idea gained ground, and ten years later it began to appear in British textbooks. In 1911 a separate column was first allotted to diseases of the thymus in the annual report of the Registrar-General. Since then many attacks have been made on it, the most authoritative being that of a joint committee of the Medical Research Council and the Pathological Society of Great Britain, which in 1931 after a careful study of 680 necropsies, that reported, " there is no evidence that the so-called status thymolymphaticus has any existence as a pathological entity."7 Littleton et al.6 have examined one of the five hypotheses accounting for death in " status thymolymphaticus "-namely, that the thymus can compress the trachea In careful anatomical and and lead to suffocation. found no evidence suggesting studies they radiographic that this might happen even if the gland were enlarged In the young, radiography of the or abnormally placed. thymus can be very difficult ; the range of normal is wide, and there is no absolute measure of enlargement. The vascular shadows in the infant’s mediastinum vary greatly in shape and width, especially if the film is taken in expiration or while the child is screaming (a glance at the jaw may help to settle this point). Screening is always advisable in the doubtful case, but lateral views of the chest are seldom helpful. It has long been uncertain whether a normal thymus can be seen, but it is now generally agreed that the small triangular projections from the mediastinum-the so-called sail shadows-can represent the edges of a normal thymus. Sometimes slight scoliosis or a mediastinal shift, secondary to collapse or agenesis of lung, may possibly displace the gland and cause its profile to appear. 1. Molony, C. J., Parmelee, A. H. J. Amer. med. Ass. 405. 2. Coursin, D. B. Ibid, p. 406. 3. Report of the Council on Pharmacy and Chemistry.
1954, 154, Ibid, 1951,
147, 322. 4. Snyderman, S. E., Carretero, R., Holt, L. E. J. clin. Nutr. 1953, 1, 200. 5. Dodwell, H. B. Brit. med. J. Jan. 16, 1954, p. 149. 6. Littleton, J. T., Motsay, D. S., Perry, S. P. Amer. J. Dis. Child. 1953, 86, 705. 7. See Lancet, 1931, i, 593.
Until these
points were recognised, thymic enlargement commonly diagnosed, and radiology was thus on the side of those who wish to keep status thymolym. phaticus alive or at least unburied. Among these, Ucko * has lately suggested that thymic and lymphoid hyper. plasia reflects pituitary-adrenocortical deficiency; and Neale9 remarks that in a morbid-anatomical study of cases of status thymolymphaticus he found that the adrenal glands were commonly small. Neale suggests that a skilled team should investigate the adrenocortical reserve of patients with suspected status thymolymphaticus. So
was
the would-be interrers
once more
find their way barred.
BIOPSY OF THE LIVER THE present method of aspiration biopsy of the liver was introduced by Iversen and Roholm 10 in 1939. Zamcheck and his colleagues 11 12have now appraised this ASPIRATION
investigation. Among 20,016 patients who underwent aspiration biopsy the mortality was 0-17%; and excluding cases which by today’s criteria would not be submitted to it the mortality was 0-085%. Schiff13 and Haex 14 had not a single fatality in 2800 cases. The principal risks are haemorrhage due to tearing of the liver, and bile peritonitis from perforation of a distended intra. hepatic duct. This second complication has been recorded only in association with extrahepatic biliary obstruction; so the signs of bile peritonitis after aspiration biopsy are a strong indication for immediate laparotomy. An impressive list of the diseases in which this investigation has been essential for diagnosis in individual cases includes amyloidosis ; Gaucher’s disease; Kinnier Wilson’s disease ; hsemochromatosis ; various grantdomatous lesions, including tuberculosis, leprosy, brucel. losis, and sarcoidosis; fungal infections; infectious mononucleosis ; leptospirosis ; toxic hepatitis ; lymphomas ; leukaemia, ; and many of the parasitic infections, such as kala-azar, hydatid disease, and schistosomiasis. von Falkenhausen et al.15 suggest that liver biopsy be considered in all obscure cases where a definite diagnosis has not been reached by other methods. Biopsy has revealed the uncertainty of clinical diagnosis of liver disorders even when based on a complete history, physical examination, general laboratory and liver-function tests, and radiographic examination. Thus Berk and Shay" found that in 12 out of 45 cases the diagnosis had to be changed as a result of the biopsy ; and Moyer and Worl11 found that almost a third of their patients diagnosed clinically as having cirrhosis in fact had only fatty liver without fibrosis. Perhaps the greatest diagnostic value of aspiration biopsy is in differentiating between " medical " and "surgical " jaundice, since "surgical" jaundice requires urgent operation, which in " medical" jaundice is strongly contra-indicated and is associated with a high mortality. Although usually this differentiation is fairly easy, in about 15% of cases an exact diagnosis is impossible without histological examination. With few exceptions this establishes the difference, especially in the early stages. Procrastination is to be avoided since as time goes on the characteristic parenchymal changes of hepatitis tend to be obscured and the danger of biopsy in obstructive jaundice increases. Against the potential dangers of needle biopsy have to be set its advantages. In 46 of 6062 necropsies at the Mallory Institute of Pathology 18 unsuspected gall-stone obstruction of the common bile-duct was found, and in 8. 9. 10. 11. 12. 13. 14. 15.
Ucko, H. Brit. med. J. Feb. 13, 1954, p. 398. Neale, A. V. Ibid, March 6, 1954, p. 582. Iversen, P., Roholm, K. Acta med. scand. 1939, 102, 1. Zamcheck, N., Sidman, R. L. New. Engl. J. Med. 1953, 249, 1020. Zamcheck, N., Klausenstock, O. Ibid, p. 1062. Schiff, L. Cited by N. Zamcheck and R. L. Sidman (footnote 11). Haex, A. J. C. Ned. Tijdschr. Geneesk. 1950, 94, 3072. von Falkenhausen, M., Konig, J., Nagel, H. H. Dtsch. med. Wschr. 1948, 73, 88. 16. Berk, J. E., Shay, H. J. Amer. med. Ass. 1952, 148, 109. 17. Moyer, J. H., Worl, O. A. Amer. J. med. Sci. 1951, 221, 28. 18. Klausenstock, O., Zamcheck, N., Robbins, S. Cited by N. Zamcheck and R. L. Sidman (footnote 11).