TOWARDS TELEVISION GASTROSCOPY

TOWARDS TELEVISION GASTROSCOPY

46 In 4 specimens the body actually expanded at its left extremity, forming a flattened enlargement-a marked contrast to some of the narrow pointed ta...

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46 In 4 specimens the body actually expanded at its left extremity, forming a flattened enlargement-a marked contrast to some of the narrow pointed tails previously encountered. We also found that the tail of the pancreas proved as variable in its relation to the spleen as it was in shape. In 19 it was closely applied to the spleen, lying on the pancreatic impression inferior to the hilum. The area of contact between the pancreas and spleen was very large in 1 case, extending from a point near the upper margin of the hilum to the lower pole of the spleen. In contrast, in 8 cases the pancreas just touched the spleen, and was easily separated with the finger when lifting the spleen anteriorly. In 11 cases the pancreas did not reach as far as the spleen, the gland ending in the lienorenal ligament, or on the surface of the kidney. In 1 instance, the end of the pancreas was F/2 in. from the spleen, as in the short pancreas illustrated by

Grant.55 The left end of the pancreas is therefore a somewhat variable structure, both in its shape and in its relationship to the spleen, and Professor Aird’s " retrograde pancreaticojejunostomy " would appear to be more satisfactory than "caudal pancreaticojejunostomy."6 Careful technique, such as described by Wilkie, Learmonth,7 and Cattell8 is also advisable when performing splenectomy in order to avoid damaging the tail of the

Dancrea.s.

JAMES A. Ross. CIRCUMCISION WITH BONE-CUTTER

SIR,-The correspondence on circumcision initiated Dr. Skeggs (June 8) illustrates the fundamental

by

contrast between Dogma and Reason-between the man of religion (who knows he is right) and the man of science (who knows he is wrong). There remains some doubt as to which is the more practical philosophy. The rabbi circumcises with an inward serenity and an outward simplicity, confident that. he is doing the right thing, at the right time, in the right way. The doctor argues interminably as to how the operation should be performed, when it should be done, and whether, indeed, it should ever be done at all. My own contribution, rather a futile one, to this evergreen problem was to use-for a time-an instrument designed to cut neither flesh nor bone, but ordinary common or garden wire. It attracted me, partly because of its powerful crushing action, but mainly because of its singularly appropriate name. It can be obtained at any reputable ironmonger’s and is catalogued under the

heading : " Nippers, end-cutting, double-toggle." South Mymms, Herts.

V. J. DOWNIE

A THOUSAND CHAMBER POTS

SIR,-In common with many others who are concerned with the care of the chronic mental patients, we wait with impatience for the day when the recommendation of the Royal Commission will be enacted and the present emphasis on custodial care will give way to a therapeutic attitude to the problem. Meanwhile, within the present system and without expense, much can be done to humanise and civilise the conditions of many thousands of patients if it is recognised that degradation is not an essential feature of chronic mental illness. We recognised that one of the most disgusting aspects of hospital life was the chamber pot and the morning slon parade. and it was decided that patients could be 5. Grant, J. C. B. A Method of Anatomy. London, 1952 ; p. 263. 6. Wilkie, D. P. D., Miles A. Operative Surgery. London, 1936 ; p. 554. 7. Learmonth, J. Brit. med. J. 1951, ii, 67. 8. Cattell, R. B., Warren, K. W. Surgery of the Pancreas. Phila-

delphia, 1953 ; p. 214.

allowed normal lavatory facilities. Side-rooms and dormitories have been left open, lavatories made accessible, and the chamber pots removed. The many complications including wet beds predicted by the pessimists have not occurred and there is a marked net gain in upgrading the wards. An administrative problem has, however, been produced. How does one dispense with 1000 unwanted chamber pots ? The suggestions so far have not been very

helpful. D. E. MUNRO C. B. WILLIAMSON.

Stanley Royd Hospital, Wakefield.

TOWARDS TELEVISION GASTROSCOPY Sm,-Various systems have recently been suggested to replace the present rigid gastroscopes with smaller

flexible -anitS.1-3 The final solution of this problem might involve an electronic scanning system, but I should like to point out the possibility of using a mechanicalscanning principle, with which we have made some preliminary experiments although no complete unit has yet been built. "

The

"

angular or horizontal scanning is* produced by rotating the whole pick-up head of the television sonde. The vertical " scanning is obtained from a rotating mirror in front of a lens. The image is focussed on, and moves over, a diaphragm with a pinhole. The hole determines the size of the image elements and selects the light from each of them during the The transscanning. mitted light falls on a photoconductive element (e.g., germanium or cadmium sulphide) or a phototransistor. After amplification of the photocurrent outside the patient, the image can be "

observed

on a

monitoring

television

screen.

The cable to the pickup head contains electrical leads to the light source and to the photoconductive element, a mechanical transmission for focussing the image on the diaphragm, and possibly an air-inlet hose for filling the stomach or the intestinal tract. The rotation of the mirror can be synchronised with the rotation of the whole pick-up head. This can Optical system of the television pick-up be done by a gear head’for endoscopy. system between a fixed flexible tube and the inner rotating tube carrying the leads. Other possible ways to rotate the mirror are by means of a tiny air-turbine or an electric motor. Colour transmission can be obtained if three-coloured mirrors are used rotating around the same axis. To eliminate the need for an intense light source, the filament from the incandescent lamp can be focussed on the particular row of image-elements scanned by the mirror ; or, alternatively, a system can be constructed where a point source of light scans the object either simultaneously with the mirror pick-up scanning, or without any pick-up scanning in a fashion similar to the ’ Vitascan ’ system used in colour television. °

Although the use of mechanical moving parts is a disadvantage in an instrument for routine work, the system described has the advantage that it can be constructed with electronic components now available. The 1. Wallman, H., 2. Stanford, B. 3. Frank, W. E.

Rosengren, B. Lancet, 1956, ii, 1311. Ibid, 1957, i, 101. Science, 1957, 125, 871.

47

mechanical dimensions (the pick-up head is about 5 cm. long and has a diameter of about 1 cm.) would allow inspection of regions of the intestinal tract inaccessible to other optical instruments. The property of certain photoconductive materials of having a large inherent current multiplication is of advantage in that they require less light intensity than other suggested pick-up systems. The slow scanning-speed (a few seconds per turn of the pick-up head) might be the greatest disadvantage, since it probably necessitates the use of a

storing system (e.g., a colour-photographic recording) inspection of the image. The recently developed image-storage tubes (e.g., HughesTonotron,’ or R.C.A. Type 6866 Display Storage Tube’) could also be used for the same purpose if the images on three tubes equipped with appropriate colour filters were optically for detailed

mivff) Karolinska Institutet, Stockholm 60, Sweden.

BERTIL JACOBSON.

STEATORRHŒA AND HYPOPARATHYROIDISM

SIR,-Dr. Salvesen, in his letter of June 15, has slightly own communication. I attempted point out merely the coincidence of steatorrhoea and hypoparathyroidism, whether the latter was primary, secondary, or pseudo. The actual relationship of the

misunderstood my

to

two states is another

matter, and Dr. Salvesen’s

own

theory (of secondary parathyroid failure from undernutrition of the gland) indicates one possible connection. Unfortunately not all cases of the " syndrome show idiopathic hypoparathyroidism, since some do not respond to parathyroid extract (e.g., my own case). "

W. P. U. JACKSON. Salvesen seeks to draw a distinction between idiopathic hypoparathyroidism associated with steatorrhoea and secondary hypoparathyroidism due to steatorrhoea. It is not clear, however, how this distinction can be made, or what reasons he has for thinking that they are not one and the same condition.

SIR,-Professor

Gardiner Institute, Western Infirmary, Glasgow, W.1.

B. E. C. NORDIN.

ACUTE SUPPRESSION OF URINE AND LIVER FAILURE ACCOMPANYING ECLAMPSIA SiR,-The interesting account by Dr. Saltoun and Dr. Kinn (June 22) suggests that readers might be

interested in a case recently under my care in the small obstetric unit in the Sir Henry Elliot Hospital, Umtata, C.P.

Postpartum convulsions developed in a multiparous Tembo native soon after returning to her ward following a normal parturition. The convulsions seemed typically eclamptic, were severe, and were followed by coma. The blood-pressure was raised (diastolic over 100 mm. Hg) There was no past history and no antenatal examination had been made. She was given paraldehyde 5 ml. intramuscularly ; some 12 oz. of black urine was collected soon afterwards. It contained very scanty erythrocytes, no pus cells, a few casts, and albumin; the colour was due to haemoglobiii. Blood examination was negative for malarial parasites ; Wassermann reaction was negative. There is no malarial fever in the Transkei. A colleague, Mr. 1. R. Ross, advised Bull’s diet.! (400 g. dextrose, 100 g. arachis oil, acacia q.s. to 1 litre of water, given slowly through a Ryle’s tube every 24 hours). Nothing else was given at all, except a few teaspoonfuls of cold water occasionally to comfort the patient, who cooperated excellently. This was continued for 3 days, before the secretion of urine began to return, slowly at first but soon more rapidly : the daily volume was recorded and an equivalent quantity of extra water was allowed, and the glucose and oil mixture given by mouth ; this induced nausea if not given in very small amounts slowly and at intervals. Soon there was an astonishing diuresis of up to 18 pints a day of colourless clear urine of specific gravity about 1-005 1.

Bull, G. M., Joekes, A. M., Lowe, K. G. Lancet, 1949, ii, 229.

less at first. She recovered rapidly, and we had some diffiin persuading her to remain in hospital ; we feared that grave electrolyte imbalance might develop after return to her village. Urine chlorides were tested repeatedly and never fell below a normal minimum. We did not know what was happening to her potassium store, so Hartmann’s solution was given, as well as a litre of whole blood. The baby lived, and had almost entirely breast-feeding by the time they left hospital. There was no pyrexia, and therefore no antibiotic was given. Both the patient and her relatives denied all history of epilepsy, and she had none of the scars of injury and burns so characteristic of this affliction or

culty

amongst primitive peoples.

Haemoglobinuria is a known complication of eclampsia.2 R. W. NICHOL. AN EFFECT OF MEPROBAMATE WITHDRAWAL IN RATS

SiR,-Swinyard et al.3 report hyperexcitability in mice from which meprobamate was suddenly withheld after sustained administration. They refer to reports of seemingly similar phenomena in humans. We have noticed in rats a possibly related sequel to sudden meprobamate withdrawal. We have been testing various substances for their counteraction of aminopterin toxicity in weanling rats. We were led to try meprobamate in this connection because patients " radiomimetic drugs " receiving radiotherapy-or the mustine (nitrogen mustard), tretamine (T.E.M.) or T.P.A.are much less prostrated and do not suffer the usual anorexia if meprobamate is conjointly administered. Aminopterin and other non-competitive folacin-antagonists are*" radiomimetic "

agents. When weanling female Sprague-Dawley rats are given aminopterin 0’3 mg. per kg. per day orally dissolved in milk, they fail to gain weight and usually stop eating completely by the 14th day ; there are few if any survivors by the 21st day.4 In three successive series of twelve rats each, where this aminopterin dosage was supplemented by meprobamate (200 mg. per kg. per day) (also orally dissolved in milk), the animals were in visibly better condition throughout the experiment ; they ate well and gained weight, and there were eight, six, and eleven survivors severally at the 28th day. Fortuitously, at the conclusion of the first series the survivors were not killed but returned to stock, and to the control diet (which in this instance was the regular allotment of homogenised milk and enriched white bread, minusboth aminopterin and meprobamate). Usually, aminopterinpoisoned animals, if not moribund at the time of return to control diet, may recover after a return to the control diet ; this has been done where genetic studies were contemplated. It was found, however, that those animals which had received meprobamate, and had continued well in the face of the concurrent

aminopterin administration, invariably stopped eating

within 24 hours of the withdrawal, and all were dead within 3 days. This happened in three successive series.

This observation recalls the clinical impression (which, unlike the observation on rats, is difficult to establish conclusively) that patients with neoplastic disease, who have been receiving meprobamate, but have it discontinued on admission to hospital for radiotherapy or radiomimetic drugs, have more acute side-effects than they would have had if they had not been given meprobamate at all. Since meprobamate has been found to be an effective palliative for the usual side-effects of radiation or radiomimetic therapy, we caution against its arbitrary or inadvertant withdrawal under these

circumstances. With increasing discussion of possible mutagenic and other baneful effects of radiation, and with the realisation that the various alkylating and cytotoxic agents now being exploited in cancer therapy must (at least theoretically) have the same potentialities as ionising radiation, 2. Baird, D. In Kerr, J. M. M., and others. Combined Textbook of Obstetrics and Gynæcology. Edinburgh, 1950 ; p. 462. 3. Swinyard, E. A., Hin, L., Fingl, E. Science, 1957, 125, 739. 4. Barnard, R. D., Freeman, M. D. Amer. J. dig. Dis. 1955, 22, 76.