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Subphrenic Abscess: a Changing Pattern
301
explanation for the absence of similar changes in patients with Burkitt lymphomas is that the phase of activity is cut short when neoplasia develops. Alternatively, the consequences of a long spell of chronic malarial infection may be more complex than appear at first sight. In particular, there may be suppression as well as stimulation of the R.E. system. Immunosuppressive effects of malarial parasites have been demonstrated in mice infected with Plasmodium berghei,l7 and an immunosuppressive phase may develop at some stage in longenhanced
R.E.
sustained malarial infection in man; stance has already been reported.13
one
such in-
JERUSALEM 18,19 has shown that mice repeatedly berghei develop a non-leukarmic malignant lymphoma which is morphologically similar to the Burkitt tumour. Of particular interest are the observations that the incidence of lymphomas in the mice is " strongly dependent on the severity of the primary infection " (cited by BURKITT 7) and that the infected mice are immunodepressed and do not reject foreign skin-grafts (cited by SALAMAN 1’). JERUSALEM found virus particles in the mouse tumours, though their nature and significance are as yet uncertain. He ’suggests that they represent latent virus which has been activated by the malarial infection; but BURKITT points outthat they may equally represent superinfection in a lymphoid system which has been modified by malarial infection. infected with P.
It may be concluded that the epidemiological evidence linking Burkitt lymphoma and holoendemic malaria is wholly convincing. Malaria, according to 0’CorroR, "has proved to be the single factor so far identified which is common to, and at the same time is more or less limited to, those regions of the world in which Burkitt’s lymphoma occurs with undue frequency." It follows that eradication of malaria from such localities should reduce the incidence of Burkitt lymphoma to the very low level found in other parts of the world. But the actual contribution of malaria to the etiology of Burkitt lymphoma is still obscure. More information is required about R.E. function in these patients, in addition to specific antitumour immune responses; evidence of hyperimmunity would be particularly valuable.13 Much remains to be learned about the kinds of immunelogical damage which sustained malarial infection may inflict on the host. Immune stimulation and immune depression have been considered here, but there are other possibilities such as the elaboration of enhancing antibodies and the production of tolerance.Lastly, we are wholly ignorant of events in any transitional phase when neoplastic changes supervene-a phase which perhaps represents the final breakdown of a precarious balance between a critical mass of proliferating lymphoid cells and host resistance. 17. Salaman, M. H. Proc. R. Soc. Med. 1970, 63, 11. 18. Jerusalem, C. Tropenmed. Parasitol. 1968, 19, 94. 19. Jerusalem, C. in Lymphatic Tissue and Germinal Centers (edited by L. Fiore-Donati and M. G. Hanna, Jr.); p. 497, New York, 1969.
Subphrenic
Abscess: Pattern
a
Changing
THANKS to chemotherapy, the change in outlook in many infections and in postoperative sepsis in the past thirty years has exceeded all other advances of medicine. As with many therapeutic benefits, some payment is extracted by the complications to be expected whenever powerful drugs are used. Subphrenic abscess is a case in point. Medical progress has changed the shape of the disease; in its new guise, it is not always recognised. The increasing chronicity of subphrenic abscess was noted by ROSENBERG 1; and later reports confirm this change and add to the complexity of the situation. " SANDERS2 likens subphrenic abscess to a volcano; it can rapidly build up a crater of sepsis giving the patient an acute illness, with a clear-cut diagnosis.... On the other hand, it may linger apparently quiescent, causing only a slight fever, only to erupt unexpectedly some weeks or months later. Finally, it may be, like Vesuvius, apparently extinct, apart from occasional rumbles, making its presence felt only by causing chronic ill health." The new picture has taken years to gain wide acceptance 3; and the changes now being more widely discussed were clearly recognised and beautifully described by HARLEY4 in 1955. The clinical significance of the change is clear. The diagnosis must be suspected in a patient who has had an abdominal operation many months or even many years ago, particularly if the postoperative course was stormy, and who has since been in ill health, perhaps with chronic anxmia, intermittent pyrexia, and ill-defined symptoms. Unless chronic subphrenic abscess is borne in mind, the next steps in diagnosis will never be taken. X-ray examination is the best guide. HARLEY5 points to the value of taking at least four pictures with the patient upright: posteroanterior and lateral chest, and penetrating localised posteroanterior and lateral views centred on the diaphragm. Elaborate techniques beyond this, he finds necessary only occasionally. SANDERS2 points out that screening the diaphragm is useless, since it becomes fixed in both infective and embolic disease at the base of the lung. He advocates pneumoperitos did much earlier) for the detection neum (as HARLEY of a walled-off abscess, or pneumogastrium, by means of Seidlitz powder, as preferable to barium examinations. Intravenous pyelography to exclude perinephric abscess or pyonephrosis is obviously useful; and another helpful radiological investigation is examination in the lateral decubitus position, affected sidedown, with 15° head-down tip to displace the pleural effusion (with barium in the stomach for left-sided cases). The basic difficulty is to define the diaphragm, 1. 2. 3. 4. 5. 6.
Rosenberg, M. Lancet, 1968, ii, 379. Sanders, R. C. Br. J. Surg. 1970, 57, 449. Rosenberg, M. Proc. R. Soc. Med. 1969, 63, 323. Harley, H. R. S. Subphrenic Abscess. Oxford, 1955. Harley, H. R. S. Proc. R. Soc. Med. 1970, 63, 319. Harley, H. R. S. Thorax, 1949, 4, 1.
302
and the penetrated views will be the most likely to do that. Radioisotope scanning of liver and lung to display the gap between them has been advocated,7.8 but scanning is of value only in detecting large collections, which can usually be identified radiologically.99 Missed diagnosis is more common than misdiagnosis. Nevertheless, a chronic abscess has presented as a right hypochondrial mass after abdominal operations for malignant disease and been taken for hepatic metastases. Drainage of pus led to recovery.10 As for treatment, most surgeons favour the extraserous approach in both acute and chronic subphrenic abscess. Since the overwhelming majority of abscesses now arise anteriorly, this operation is particularly suitable. Subcostal incisions are those most favoured. The chief point thereafter is drainage, which can be achieved satisfactorily only by repeated sinography. The tube is removed when the radiograph shows only a tube track and no cavity beyond.
ATLANTIC TRENDS
JUST when the system of health-care delivery in Britain is being urged to turn to out-of-pocket payments or insurance to supplement (or compensate for cuts in) Treasury funding out of general taxation, the trend in America seems to be in the opposite direction. Speaking at the Hospital Centre in London last week, Mr. Walter J. McNerney, president of the National Blue Cross Association, welcomed the consensus that it was no longer enough to assume that a largely freemarket health-care system would be self-regulatory and that all would come right in the end: for Britain, on the other hand, he could see no alternative to fostering private insurance as a means of paying for medical services. One can buy time, he said, by allowing buildings to deteriorate, by underpaying staff, and by benefiting from changes in the pattern of communicable disease (and few would disagree that in Britain we have done all these things), but a major reappraisal would be needed one day, and for the N.H.S. that day might already be close. But just as in Britain there is no general agreement about the best method for raising extra money for health, so too, across the Atlantic, they had got no further than a recognition of a need for change, although ideas abound. Mr. McNerney, whose organisation coordinates the private health-insurance plans of some 92 million Americans, was no uncritical apologist for the system which Blue Cross largely underpins. But he pointed out that no scheme which attracts nearly 7% of the gross national product, spends $2000 million on construction and$1600 million on medical research each year, and has set up twelve new medical schools in the past five years can be wholly bad. However, there were defects, and these had become and would remain important issues in the United States, especially among organised labour. 7.
Boden, G. R., Holzwasser, G.
R.
Surgery Gynec. Obstet. 1964, 119,
601.
8. Brown, D. W. Am. J. Surg. 1965, 109, 521. 9. Croft, D. M. Personal communication. 10. Harrison, N. W. Br. J. Surg. 1970, 57, 456.
On the debit side were the wide disparity in physician/ population and nurse/population ratios and the real differences in morbidity and mortality between the poor and the rest; and costs were rising sharply. One idea for improving the situation would be to make it harder to start a new hospital: Government or insurance money would not be forthcoming until the prospective hospital conformed to a plan, and here an emphasis on local needs might be preferable to some sort of national master plan. The cost-plus basis for charging for items of service was inflationary, and greater emphasis should be put on prospective payments and group practices (a development commented on favourably by one British visitor 1). One could do a lot more with all the data that the system generated-e.g., by setting up norms for care under different diagnostic headings so that an abnormally long admission for an uncomplicated procedure could be referred back to the unit concerned, and by publicising vagaries in patient costs between comparable hospitals. Combinations of these ideas might go a long way towards improving productivity in the provision of medical care, but what about access to it for the poorer sections of the community, many of whom have no insurance ? An idea for a national health insurance is in Congress; but McNerney was not certain how one could guarantee that doctors would practise in rural areas and in city slums. Geographically directed national service for newly qualified doctors, and primary care provided by assistants without full medical qualifications but with access to specialist advice, and a crash programme centred on neighbourhood medical centres backed by Federal money were some ideas: all are controversial. McNerney believes that America is not short of doctors,2but so long as drastic solutions such as the ones he proposes are needed the U.S. Department of Labor3 and the Council on Health Manpower4 are not likely to withdraw their demands for more doctors. And so long as such demands exceed domestic supply the dilemma of medical emigration from countries which can least afford doctors to countries with least need will continue.
CLASSIFICATION OF INFANTILE MALNUTRITION THE various clinical syndromes associated with malnutrition in children have over the years been given many different names.5 Recently, however, there has been fairly general acceptance of the terms kwashiorkor and marasmus; and most workers hold that kwashiorkor is caused by a diet adequate in calories but deficient in protein, while marasmus results from a prolonged deficit of both calories and protein. Unfortunately, there is no real proof of these simple causal relationships. Published work shows that these terms have often been used to indisevere
Holland, W. W. Lancet, July 25, 1970, p. 202. McNerney, W. J. New Engl. J. Med. 1970, 282, 1458. Margulies, H., Block, L. S. Foreign Medical Graduates in the United States. Cambridge, Massachusetts, 1969. 4. Council on Health Manpower J. Am. med. Ass. 1969, 210, 2078. 5. Trowell, H. C., Davies, J. N. P., Dean, R. F. A. Kwashiorkor. London, 1954.
1. 2. 3.
explanation for the absence of similar changes in patients with Burkitt lymphomas is that the phase of activity is cut short when neoplasia develops. Alternatively, the consequences of a long spell of chronic malarial infection may be more complex than appear at first sight. In particular, there may be suppression as well as stimulation of the R.E. system. Immunosuppressive effects of malarial parasites have been demonstrated in mice infected with Plasmodium berghei,l7 and an immunosuppressive phase may develop at some stage in longenhanced
R.E.
sustained malarial infection in man; stance has already been reported.13
one
such in-
JERUSALEM 18,19 has shown that mice repeatedly berghei develop a non-leukarmic malignant lymphoma which is morphologically similar to the Burkitt tumour. Of particular interest are the observations that the incidence of lymphomas in the mice is " strongly dependent on the severity of the primary infection " (cited by BURKITT 7) and that the infected mice are immunodepressed and do not reject foreign skin-grafts (cited by SALAMAN 1’). JERUSALEM found virus particles in the mouse tumours, though their nature and significance are as yet uncertain. He ’suggests that they represent latent virus which has been activated by the malarial infection; but BURKITT points outthat they may equally represent superinfection in a lymphoid system which has been modified by malarial infection. infected with P.
It may be concluded that the epidemiological evidence linking Burkitt lymphoma and holoendemic malaria is wholly convincing. Malaria, according to 0’CorroR, "has proved to be the single factor so far identified which is common to, and at the same time is more or less limited to, those regions of the world in which Burkitt’s lymphoma occurs with undue frequency." It follows that eradication of malaria from such localities should reduce the incidence of Burkitt lymphoma to the very low level found in other parts of the world. But the actual contribution of malaria to the etiology of Burkitt lymphoma is still obscure. More information is required about R.E. function in these patients, in addition to specific antitumour immune responses; evidence of hyperimmunity would be particularly valuable.13 Much remains to be learned about the kinds of immunelogical damage which sustained malarial infection may inflict on the host. Immune stimulation and immune depression have been considered here, but there are other possibilities such as the elaboration of enhancing antibodies and the production of tolerance.Lastly, we are wholly ignorant of events in any transitional phase when neoplastic changes supervene-a phase which perhaps represents the final breakdown of a precarious balance between a critical mass of proliferating lymphoid cells and host resistance. 17. Salaman, M. H. Proc. R. Soc. Med. 1970, 63, 11. 18. Jerusalem, C. Tropenmed. Parasitol. 1968, 19, 94. 19. Jerusalem, C. in Lymphatic Tissue and Germinal Centers (edited by L. Fiore-Donati and M. G. Hanna, Jr.); p. 497, New York, 1969.
Subphrenic
Abscess: Pattern
a
Changing
THANKS to chemotherapy, the change in outlook in many infections and in postoperative sepsis in the past thirty years has exceeded all other advances of medicine. As with many therapeutic benefits, some payment is extracted by the complications to be expected whenever powerful drugs are used. Subphrenic abscess is a case in point. Medical progress has changed the shape of the disease; in its new guise, it is not always recognised. The increasing chronicity of subphrenic abscess was noted by ROSENBERG 1; and later reports confirm this change and add to the complexity of the situation. " SANDERS2 likens subphrenic abscess to a volcano; it can rapidly build up a crater of sepsis giving the patient an acute illness, with a clear-cut diagnosis.... On the other hand, it may linger apparently quiescent, causing only a slight fever, only to erupt unexpectedly some weeks or months later. Finally, it may be, like Vesuvius, apparently extinct, apart from occasional rumbles, making its presence felt only by causing chronic ill health." The new picture has taken years to gain wide acceptance 3; and the changes now being more widely discussed were clearly recognised and beautifully described by HARLEY4 in 1955. The clinical significance of the change is clear. The diagnosis must be suspected in a patient who has had an abdominal operation many months or even many years ago, particularly if the postoperative course was stormy, and who has since been in ill health, perhaps with chronic anxmia, intermittent pyrexia, and ill-defined symptoms. Unless chronic subphrenic abscess is borne in mind, the next steps in diagnosis will never be taken. X-ray examination is the best guide. HARLEY5 points to the value of taking at least four pictures with the patient upright: posteroanterior and lateral chest, and penetrating localised posteroanterior and lateral views centred on the diaphragm. Elaborate techniques beyond this, he finds necessary only occasionally. SANDERS2 points out that screening the diaphragm is useless, since it becomes fixed in both infective and embolic disease at the base of the lung. He advocates pneumoperitos did much earlier) for the detection neum (as HARLEY of a walled-off abscess, or pneumogastrium, by means of Seidlitz powder, as preferable to barium examinations. Intravenous pyelography to exclude perinephric abscess or pyonephrosis is obviously useful; and another helpful radiological investigation is examination in the lateral decubitus position, affected sidedown, with 15° head-down tip to displace the pleural effusion (with barium in the stomach for left-sided cases). The basic difficulty is to define the diaphragm, 1. 2. 3. 4. 5. 6.
Rosenberg, M. Lancet, 1968, ii, 379. Sanders, R. C. Br. J. Surg. 1970, 57, 449. Rosenberg, M. Proc. R. Soc. Med. 1969, 63, 323. Harley, H. R. S. Subphrenic Abscess. Oxford, 1955. Harley, H. R. S. Proc. R. Soc. Med. 1970, 63, 319. Harley, H. R. S. Thorax, 1949, 4, 1.
302
and the penetrated views will be the most likely to do that. Radioisotope scanning of liver and lung to display the gap between them has been advocated,7.8 but scanning is of value only in detecting large collections, which can usually be identified radiologically.99 Missed diagnosis is more common than misdiagnosis. Nevertheless, a chronic abscess has presented as a right hypochondrial mass after abdominal operations for malignant disease and been taken for hepatic metastases. Drainage of pus led to recovery.10 As for treatment, most surgeons favour the extraserous approach in both acute and chronic subphrenic abscess. Since the overwhelming majority of abscesses now arise anteriorly, this operation is particularly suitable. Subcostal incisions are those most favoured. The chief point thereafter is drainage, which can be achieved satisfactorily only by repeated sinography. The tube is removed when the radiograph shows only a tube track and no cavity beyond.
ATLANTIC TRENDS
JUST when the system of health-care delivery in Britain is being urged to turn to out-of-pocket payments or insurance to supplement (or compensate for cuts in) Treasury funding out of general taxation, the trend in America seems to be in the opposite direction. Speaking at the Hospital Centre in London last week, Mr. Walter J. McNerney, president of the National Blue Cross Association, welcomed the consensus that it was no longer enough to assume that a largely freemarket health-care system would be self-regulatory and that all would come right in the end: for Britain, on the other hand, he could see no alternative to fostering private insurance as a means of paying for medical services. One can buy time, he said, by allowing buildings to deteriorate, by underpaying staff, and by benefiting from changes in the pattern of communicable disease (and few would disagree that in Britain we have done all these things), but a major reappraisal would be needed one day, and for the N.H.S. that day might already be close. But just as in Britain there is no general agreement about the best method for raising extra money for health, so too, across the Atlantic, they had got no further than a recognition of a need for change, although ideas abound. Mr. McNerney, whose organisation coordinates the private health-insurance plans of some 92 million Americans, was no uncritical apologist for the system which Blue Cross largely underpins. But he pointed out that no scheme which attracts nearly 7% of the gross national product, spends $2000 million on construction and$1600 million on medical research each year, and has set up twelve new medical schools in the past five years can be wholly bad. However, there were defects, and these had become and would remain important issues in the United States, especially among organised labour. 7.
Boden, G. R., Holzwasser, G.
R.
Surgery Gynec. Obstet. 1964, 119,
601.
8. Brown, D. W. Am. J. Surg. 1965, 109, 521. 9. Croft, D. M. Personal communication. 10. Harrison, N. W. Br. J. Surg. 1970, 57, 456.
On the debit side were the wide disparity in physician/ population and nurse/population ratios and the real differences in morbidity and mortality between the poor and the rest; and costs were rising sharply. One idea for improving the situation would be to make it harder to start a new hospital: Government or insurance money would not be forthcoming until the prospective hospital conformed to a plan, and here an emphasis on local needs might be preferable to some sort of national master plan. The cost-plus basis for charging for items of service was inflationary, and greater emphasis should be put on prospective payments and group practices (a development commented on favourably by one British visitor 1). One could do a lot more with all the data that the system generated-e.g., by setting up norms for care under different diagnostic headings so that an abnormally long admission for an uncomplicated procedure could be referred back to the unit concerned, and by publicising vagaries in patient costs between comparable hospitals. Combinations of these ideas might go a long way towards improving productivity in the provision of medical care, but what about access to it for the poorer sections of the community, many of whom have no insurance ? An idea for a national health insurance is in Congress; but McNerney was not certain how one could guarantee that doctors would practise in rural areas and in city slums. Geographically directed national service for newly qualified doctors, and primary care provided by assistants without full medical qualifications but with access to specialist advice, and a crash programme centred on neighbourhood medical centres backed by Federal money were some ideas: all are controversial. McNerney believes that America is not short of doctors,2but so long as drastic solutions such as the ones he proposes are needed the U.S. Department of Labor3 and the Council on Health Manpower4 are not likely to withdraw their demands for more doctors. And so long as such demands exceed domestic supply the dilemma of medical emigration from countries which can least afford doctors to countries with least need will continue.
CLASSIFICATION OF INFANTILE MALNUTRITION THE various clinical syndromes associated with malnutrition in children have over the years been given many different names.5 Recently, however, there has been fairly general acceptance of the terms kwashiorkor and marasmus; and most workers hold that kwashiorkor is caused by a diet adequate in calories but deficient in protein, while marasmus results from a prolonged deficit of both calories and protein. Unfortunately, there is no real proof of these simple causal relationships. Published work shows that these terms have often been used to indisevere
Holland, W. W. Lancet, July 25, 1970, p. 202. McNerney, W. J. New Engl. J. Med. 1970, 282, 1458. Margulies, H., Block, L. S. Foreign Medical Graduates in the United States. Cambridge, Massachusetts, 1969. 4. Council on Health Manpower J. Am. med. Ass. 1969, 210, 2078. 5. Trowell, H. C., Davies, J. N. P., Dean, R. F. A. Kwashiorkor. London, 1954.
1. 2. 3.