1268

(Gabuzda et al. 1952). Bacitracin and chloranquinedel(Cohn and Longacre 1957) might be useful.Neomycin usually causes two or three loose stools a

day. Its beneficial effects might have been related merelyto this purgative action. Drastic purgation alone pro-duced some clinical and electro-encephalographic improve-ment in 2 patients and a fall of blood-ammonia level in 1.The effect, however, was not so dramatic as with neomycinand could not be sustained, because the treatment wastoo vigorous for continued use. The value of enemataand routine purgation in patients with hepatic comamust, however, be re-emphasised. Fetor hepaticus,which disappeared under neomycin therapy, was

unaffected by purgation-which fact supports the sugges-tion that this fetor is due to a substance formed bybacterial action in the gut.

Patients with the chronic syndrome are relativelyuncommon, but with the increase in the number of

portacaval shunt operations, can be expected to becomecommoner. Months or years may elapse between theanastomosis and the onset of symptoms. These maydevelop when liver-cell function diminishes in the naturalhistory of cirrhosis.

In acute coma neomycin seemed a useful treatment,but many other forms of therapy were being appliedsimultaneously, and controlled observations were impos-sible. Neomycin therapy in acute coma is based on thegood results obtained in the chronic syndrome. Theeventual fatal outcome reflects poor liver function. Poorresults would be expected in such patients (Sherlocket al. 1956).No complications were observed during prolonged

therapy with neomycin. Albuminuria was not seen,because neomycin, although nephrotoxic, is absorbed

only slightly from the gut. Staphylococcal enterocolitiswas not seen, and staphylococci were not isolated fromthe faeces ; these organisms are usually sensitive to

neomycin.Neomycin is expensive, 8 g. daily costing E19 a week

in hospital ; 4 g. may well be an adequate maintenancedose. A liquid, less refined, but cheaper preparationproved as effective as the usual tablets. It would havebeen difficult to conduct this trial without generous giftsof the antibiotic. Although its routine use is necessaryin acute coma, continuation over many months mayprove financially impossible. However, such patientswith the chronic syndrome in whom restriction of

dietary protein is ineffective are rare, and it is difficultto withhold neomycin if it means the difference betweenchronic invalidism and productive work. Attempts mustbe made to stop treatment with neomycin, but in manyinstances it will have to be resumed. Patients with

continuing deterioration of liver function may eventuallyprove refractory to this treatment.

Summary8 patients with cirrhosis and chronic portal-systemic

encephalopathy and 12 patients with acute hepatic comawere treated with neomycin sulphate 4-10 g. daily fromten hours to ten months.

6 chronic patients showed pronounced clinical benefit,which was associated with a fall in the fasting arterial-blood-ammonium level and an improvement in the

electro-encephalogram. 1 patient relapsed after tenmonths’ treatment. Fetor hepaticus was abolished in6 of 7 chronic patients.The fasting arterial-blood-ammonium level rose

gradually under treatment with neomycin.The effect on the stool flora was variable and could not

be correlated with the clinical benefit or with the fallin arterial-blood-ammonium level.

Purgation induced a partial remission in 2 patientsbut was not so effective as neomycin.

7 of 12 patients with acute hepatic coma showedinitial improvement, but other forms of treatment wereused simultaneously.Neomycin treatment had to be stopped in 2 patients

owing to severe diarrhoea.We wish to thank Dr. B. Ruebner for his bacteriological

advice in the early stages of the work ; the Medical ResearchCouncil for a maintenance grant to one of us (J. McL.) ;Messrs. E. R. Squibb and Sons for financial support and giftsof the liquid neomycin preparation ; and Messrs. Upjohnof England Ltd., for supplying us with neomycin tablets.

REFERENCES

Adams, R. D., Foley, J. M. (1953) Proc. Ass. Res. nerv. Dis. 32, 198.Atkinson, M., Barnett, E., Sherlock, J. Steiner R. E. (1955) Quart.

J. Med. 24, 77.Clancy, C. F. (1951) J. Bact. 61, 715.Cohn, I., Jr., Longacre, A. B. (1956) Antibiot. Annu. 1955-56,

p. 105.— — (1957) ibid. 1956-57, p. 257.

Conway, E. J. (1950) Microdiffusion Analysis and VolumetricError. 3rd ed., London.

Davidson, E. A., Summerskill, W. H. J. (1956) Postgrad. med. J.32, 487.

Fisher, C. J., Faloon, W. W. (1956) New Engl. J. Med. 255, 589.— — (1957) ibid. 256, 1030.

Gabuzda, G. J., Jackson, G. G., Grigsby, M. E. (1952) J. clin.Invest. 31, 631.

Hayward, N. J., Miles, A. A. (1953) Lancet, ii, 116.McDermott, W. V. jun., Adams, R. D. (1954) J. clin. Invest. 33, 1.Parsons-Smith, B. G., Summerskill, W. H. J., Dawson, A. M.,

Sherlock, S. (1957) Lancet, ii, 867.Pettet, J. R., Judd, E. S., Jr., Dearing, W. H. (1955) Proc. Mayo

Clin. 30, 373.Phear, E. A., Ruebner, B. (1956) Brit. J. exp. Path. 37, 253.

— — Sherlock, S., Summerskill, W. H. J. (1956) Clin. Sci. 15,93.

— Sherlock, S., Summerskill, W. H. J. (1955) Lancet, i, 836.Phillips, G. B., Schwartz, R., Gabuzda, G. J., Jr., Davidson, C. S.

(1952) New Engl. J. Med. 247, 239.Poth, E. J., Fromm, S. M., Wise, R. I., Hsiang, C. M. (1950) Tex.

Rep. Biol. Med. 8, 353.— Martin, R. G., Fromm, S. M., Wise, R. I., Hsiang, C. M.

(1951) ibid. 9, 631.Range, C. L., Ariatto, M. D., Engloring, G. E. (1957) Antibiot. Annu.

1956-57, p. 216.Sherlock, S., Summerskill, W. H. J., Dawson, A. M. (1956) Lancet,

ii, 689.— — White, L. P., Phear, E. A. (1954) ibid. ii, 453.

Silen, W., Harper, H. A., Mawdsley, D. W., Weirich, W. L. (1955)Proc. Soc. exp. Biol., N.Y. 88, 138.

Summerskill, W. H. J., Davidson, E. A., Sherlock, S., Steiner, R. E.(1956) Quart. J. Med. 25, 245.

Reviews of Books

The Early Diagnosis of the Acute Abdomen (llth ed.London: Oxford University Press. 1957. Pp. 188.18s.).-After36 years "Zachary Cope" (it is a significant tribute to thebook’s value that it is known thus to students everywhere)has had a face-lift-in this case the type face. The generalappearance is thus improved while the number of pages isreduced despite the addition of new material. The only scarsto be seen are in the adaptation of the original drawings byA. K. Maxwell to the new size and format. The radiographicreproductions, on the other hand, are improved. This famouswork has also received embellishment in the form of extra

chapters on the grouping of symptoms and on acute abdominalsymptoms due to vascular lesions.Closed Treatment of Common Fractures (2nd ed.

Edinburgh and London : E. & S. Livingstone. 1957. Pp. 256.50s.).-Manipulative arts are difficult to teach save by actualdemonstration, and in the treatment of fractures even instruc-tion by demonstration has its limitations ; for often a seniorsurgeon is able to prove to a junior colleague that it is possibleto improve the position of a difficult fracture, without eitherof them understanding quite how it is done. This impassein teaching young surgeons prompted Mr. John Charnley towrite this book, one of the most successful of its kind yetpublished. It describes carefully and lucidly the elementarymechanics of reduction and immobilisation, and shows how thecommonest injuries can be managed by proved methods basedon these general principles. When first published in 1950,the book was very well received. The new edition, whichincorporates additional material collected by Mr. Charnley foran American lecture tour, will be as widely studied as its

predecessor-and not only in the junior residents’ common-room. Many experienced orthopaedic surgeons will want toread it, and though some may disagree with Mr. Charnleyhere and there, few of them will put the volume down withoutdiscovering some modification of technique that would improvetheir results.