WHERE DO WE GO FROM HERE ?

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    On one point there will be no argumentnamely thetechnical brilliance of the production, by Dr. BrianStanford. The film, which is 16 mm., in colour, andruns for about 16 minutes, has been made for Messrs.Ciba Ltd.

    THROMBOCYTOPEN

    IT has always been surprising that though removalof the spleen causes so striking a remission of primarythrombocytopenic purpura, no really significant structuralchanges in the spleen have been found. The possibilitythat the spleen was producing some platelet-destroyingsubstance was soon thought of. Torrioli and Puddu 1in 1934 discovered that an extract made from the spleenremoved from a patient with thrombocytopenic purpurainjured the megakaryocytes in cultures of guineapigbone-marrow ; a similar extract of a normal spleen andof various other organs showed the presence of this

    antimegakaryocytic substance, though in lower con-ceiitrations. Later 2 they prepared a protein-free extractof a normal spleen, injected it intravenously into rabbits,and showed that there was a definite lowering of theplatelet-count in the peripheral blood ; they producedsome evidence that blood from the splenic vein containedmore of this platelet-reducing factor than blood from thesplenic artery. So there seemed to be some ground forsupposing that in primary thrombocytopenic purpurathe spleen produces an excess of a platelet-reducingsubstance ; and this, at least, provided a rationalexplanation for the success of splenectomy.Troland and Lee 3 used an acetone extract of spleens.

    They found that extracts from the spleens of threepatients with thrombocytopenic purpura injected intra-venously into rabbits caused a sharp reduction of theblood-platelets, but they could not demonstrate anyactivity in spleens of patients with hmolytic anaemiaor Bantis syndrome, or in extracts from normal spleens.So far as the evidence went, it supported the splenicsecretion theory, and Troland and Lee named thisunidentified substance " thrombocytopen." In 1941we commented that evidence both confirming anddenying the existence of thrombocytopen had appearedand that the subject remained unsettled. Up to thepresent, though different methods of preparing theextracts have been tried; and different test animals used,still no finality has been reached, because about as manyobservers denied the existence of thrombocytopen ascould find it, _and about an equal number obtainedequivocal results.A new approach has been tried by Singer and Rotter. 5

    They -argued that if thrombocytopen was formed inthe spleen, it would, in the natural course of events, gofirst to the liver and might there be inactivated ; theinconsistent results obtained so far might depend onhow much inactivation took place in the liver of thetest animal. If so, then the best test animal would beone whose liver was considerably damaged. Theytherefore used male albino rats which were given twointraperitoneal injections ,of 0-5 mg./kg. of carbontetrachloride ; this dose caused a suitable degree ojliver damage, but only minor kidney damage. Theyprepared suspensions of spleens and other organs byfreezing the tissue, then defrosting and mixing th(chopped tissue with saline. The freezing and defrostingprocess employed damaged red blood-cells and consequently some of their test animals developed hsemoglobinuria ; but it was found that injections of reccells alone did not affect the platelet-count. With thi:technique, they were able to show that a plateletlowering substance is present in the suspensions of mandifferent organs including spleen, lung, heart, kidneys

    1. Torrioli, M., Puddu, V. Policlinico, 1934, 41, 245, 647.2. Torrioli, M., Puddu, V. J. Amer. med. Ass. 1938, 111, 1455.3. Troland, G. E., Lee, F. C. Ibid, p. 221.4. Annotation, Lancet, 1941, i, 356.5. Singer, K., Rotter, R. J. Lab. clin. Med. 1949, 34, 1336.

    and brain. Normal human spleens and those frompatients with primary and secondary thrombocytopenicpurpura, and from patients with other blood diseaseswho had normal platelet-counts, all contained thrombo-cytopen in about the same concentration. Singer andRotter were also able to extract with ether the platelet-reducing substance from normal human urine and fromthe urine of thrombocytopenic patients.

    These results make it reasonably clear that there doesexist a platelet-reducing substance in organ extracts.But no. specific connection with thrombocytopenicpurpura has been found. Thrombocytopen thus joinsthe list of splenic substances having some action on blood-clotting ; others are the " splenins " described byUngar 6-splenin A which increases the bleeding-time ofguineapigs, and splenin B which has the opposite effect-and Mooltens " thrombocytosin " which increasesthe platelet level. Whether any of these agents has anyrole in the physiology of blood-clotting or plateletproduction and function is doubtful ; Singer and Rotterdo well to remind us how difficult it has proved to fitthat powerful anticoagulant heparin into any scheme ofnormal blood-clotting. -

    WHERE DO WE GO FROM HERE ?

    THOSE who attend conferences on mental healthoccasionally feel that great truths and broad principles,however well they nourish the spirit, are not entirelysustaining to ordinary psychosomatic man. He needshis halfpennyworth of bread, even though he does notlive by bread alone ; and he is even, at times, ready torisk his digestion on a handful of brass tacks. ProfessorAlexander Kennedy, who consumes brass tacks withrelish, hinted, when presiding on the first day of aconference 8 on " Mental -Health and the Family," thatperhaps our behaviour is not entirely determined ; and that it is even possible that the process of evolution maybecome orderly if we apply common sense and plainEnglish to it. The Archbishop of Canterbury, inopening the conference, also declared for plain English,exhorting psychiatrists to be distrustful-or at leastcareful-of words. We can make them mean too much,he said ; and we can use multitudes of them to meantoo little-the more tired we get the more we take refugein words ; and in this we are abetted by the dreadfulfacility of the secretary and the typewriter. Again, allwords are shorthand, but the shorthand of a particulardiscipline may be too short for good sense : he quotedthe term " psychosocial medicine," as an example. Hewas naturally undisturbed by the notions that mansbehaviour is entirely determined, or that God is aprojection of the unconscious mind ; and he felt thatmany scientists now shared his confidence. But when

    psychiatrists, as he said, explore and play about withreligion as an aspect of man-which is quite the -rightthing to do, at one level-they are in some danger ofthinking that religion has no relation to any eternalreality. Dr. Alfred Torrie, later in the discussion,remarked that any psychiatrist who professed religiousprinciples was in danger of being told by his colleaguesthat he was not quite grown up. Dr. J. L. Halliday, inhis address on social health, cautiously acknowledged thedynamic effect on society of mans religious projections,but was willing also to concede the possible existence ofan " Outer and Beyond." He dealt much with thedeterminants of human behaviour, however, andit washard to feel he had much confidence in free will.Professor Kennedv doubted whether it is wise-even ifit should prove to be true-to believe that unconsciousmotives so overwhelm our conscious designs that wecan compass nothing at all. That bit of free will, that6. Ungar, G. J. Physiol. Path. gn. 1947, 39, 219.7. Moolten, S. F. J. Mt Sinai Hosp. 1945, 12, 3.8. On March 23 and 24, arranged by the National Association for

    Mental Health.

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    bit of conscious mind, he said, is precious. And indeedit is our only tool in a world where the children of menlive-as more than one speaker hinted-in the midst ofperennial inner and outer conflict.

    Adolescents are exposed to a particularly bewilderingconflict of values. As Dame Olive Wheeler put it, theyhave great difficulty in achieving mental and moralhealth, not because of any lack in themselves, butbecause home, school, workshop, nation, and church donot speak with the same voice. There is no clearwitness in their surroundings of an accepted or accept-able ethical code. They are left floundering at a timewhen they are making their most critical choices.On the whole, the conference only formulated our

    problems ; it would be useful to know in plain English,as Professor Kennedy would say, what exactly is beingdone about them-what proportion of parents are taking-enlightened behaviour into the nursery, what schoolsare educating citizens rather than examination candi-dates, what approved schools and prisons can boast ofreform, what industries are fostering higher ethicalstandards-in short, how common sense is being applied.Perhaps this might be the subject of the next conference.

    POLIOMYELITIS IN SCOTLAND

    . So long as poliomyelitis remains an unpreventabledisease with no causal treatment, the problems of itsepidemiology will continue to be an absorbing challengeto all interested in public health. In a survey whichwe have already briefly noticed 2 Dr. Ian Sutherland, asenior medical officer of the Department of Health forScotland, has provided a detailed and valuable analysisof the Scottish experience of the 1947 epidemic in GreatBritain In essence it consists of 28 tables of statisticswith a commentary on their significance. Each tablerepresents a rearrangemerit of the information on 2002case-summary cards. Each summary card is a record ofsome 30 to 50 facts about each person notified as sufferingfrom poliomyelitis in Scotland between June 1, 1947,and Jan. 3, 1948. These essential details were obtainedby the medical officers of health, presumably not withoutmuch painstaking effort by their indispensable and stillunderpaid backroom girls-i.e., health visitors.

    Of the 2002 notifications, 626 (31-3%) proved to benot poliomyelitis. The most frequent diagnoses of those"not poliomyelitis" were " no abnormality " (14-2%)and tonsillitis (9-9%). Respiratory disease (27-0%),diseases of the nervous system (18-7%), and diseases ofthe locomotor system (14-7%) account for nearly two-thirds. The over-all incidence was 2-68 per 10,000 (1 in3731) with an over-all mortality of 8-87%. The maximumincidence was at one year of age-namely, 20.16 per10,000 (1 in 496). Of those with paralysis 9% needed.respirator treatment and almost two-thirds of these died.There was a male-to-female incidence ratio of 1-45-to 1.About one in four with poliomyelitis had no paralysis,but the proportion was higher in rutal districts, higherage-groups, and (especially in younger children) in thelater stages of the epidemic. The incidence of polio-myelitis compared with " not poliomyelitis

    " was signifi-

    cantly associated with (1) more apartments, especiallyfour or more, (2) fewer occupants, (3) higher social classin age-groups over five years, (4) better sanitation, (5) arecord of associated cases, and (6) pregnancy. Greaterseverity, shown by the need for respirator treatment orcase-fatality was associated with (1) a shorter intervalbetween onset and notification, (2) increasing age, (3)more apartments, (4) fewer occupants, (5) better sanitaryconditions, (6) higher social class. There was no signifi-cant association between severity and pregnancy. Of14 pregnant women 4 died, compared with 12 of 841. Poliomyelitis: a Survey of the Outbreak in Scotland in 1947.

    Department of Health for Scotland, Edinburgh. H.M.Stationery Office. Pp. 83. 1s. 6d.

    2. Lancet, Feb. 25, p. 369.

    non-pregnant women of the same age-groups-a differ-ence which could be expected to occur by chance aboutonce in six times.

    In his concluding paragraph Dr. Sutherland writes :" No attempt is made to sum up the observation of thesur-vey in one or two sentences. In fact the survey willhave served a useful purpose if it reinforces the,dangerof categorical statements which, on closer study, demandsuch modification or amplification that the originalsimplicity is shown to be false." But a table giving thestatistical findings for each association tested woulditself have been a summary and a great help to those notactually preoccupied with the epidemiology of polio-myelitis. In sum, however, the survey provides admirablebuilding material, and the author seems well justified inhoping " that the detailed description, when comparedwith others elsewhere, will help to establish the commonfeatures of this serious infection and, with the develop-ment of techniques of confirmation of infection, eventuallylead towards better techniques of study and control."

    CONSTITUTIONAL CHANGES

    CONSTITUTIONAL reform seems to be in the air. TheHouse of Lords, the General Medical Council, and nowthe council of the British Medical Association have allbeen considering whether their membership should notchange with the changing times. On March 29 at aspecial representative meeting of the B.M.A., Dr. J. A.Pridham, chairman of the organisation committee ofthe council, explained that during the negotiations beforethe National Health Service Act was passed they cameto realise that the link between the council and thedivisions and branches was not close enough. Thecouncil should at once know the needs and wishes of thebranches and divisions and keep them informed of whatwas cooking" at headquarters. The directly electedmembers of council would find it easier to do this iftheir constituencies were of more manageable size. Itwas therefore proposed to increase their number from 22to 39. But though the council agreed on the need formore directly elected representatives they were alsoagreed that to increase the total membership of councilwould be to render it ineffective, and they were facedwith the necessity of making economies somewhere.They therefore reluctantly suggested that the number ofex-officio members should be reduced and that the numberof members elected by the representative body shouldbe reduced from 20 to 13, mainly by discontinuing thesystem of election by group representatives. Dr. H. G.Dain put the point of view of those who opposed thesechanges. He feared that they would endanger therepresentative bodys,6ontrol of council. They shouldbe able, he declared, to choose people and not be. tieddown by areas. To.make council a_ second parliamentwould detract from the authority of the representativebody. He also made the point that the present councilcontains representatives of all types of practice. Thisbalance, he felt, might be less easy to attain if moremembers were elected from the periphery. The councilsproposals 1 were, however, ultimately passed with oneamendmentnamely, that the deputy chairman of therepresentative body was retained as an ex-officio member.

    In the afternoon the discussion on the constitution ofcouncil was interrupted to consider a series of resolutionson the relationship to the association of the autonomousbodies-the General Medical Services Committee andthe Central Consultants and Specialists Committee.Lord Horder spoke eloquently for those who viewed theirexistence with anxiety. He was uncertain of thedifference of meaning between autonomous and inde-pendent. There was a danger that the representativebody might emasculate itself by continuing to add thesebodies. Disaster could be avoided only if the repre-

    1. Brit. med. J. Jan. 28, suppl. p. 29.