1233

4. Hellsten, H., Olsson, O. Acta chir. scand. 1954, 108, 443.5. Lahey, F. H., Lium, R. Surg. Gynec. Obstet. 1937, 64, 79.6. Cattell, R. B. Surg. Clin. N. Amer. 1949, 29, 779.7. Warren, K. W. Ibid, 1951, 31, 789.8. DuVal, M. K. Ann. Surg. 1954, 140, 775.9. McDonald, J. H., Heckel, N.J. J. Amer. med. Ass. 1957, 163, 911.

sutured at once to the duodenum or jejunum, opposingmucosa to mucosa. (A severed duct of Santorini whichcan be shown to connect with the main pancreatic ductmay be ligatured with safety.) When injury to a ductat operation is not detected at the time, it usuallydeclares itself on the second postoperative day by upper-abdominal pain and pyrexia associated with raised serumor urinary amylase levels. If division of the duct of

Wirsung is suspected the region of the head of the

pancreas should be drained and repair of the ductdeferred to a more propitious time. Otherwise the

patient is treated as if he had acute pancreatitis, withcontinuous aspiration of the gastric remnant and intra-venous administration of fluids and electrolytes ; if

necessary glucose and protein hydrolysates can be givenintravenously; and the use of broad-spectrum anti-biotics, though these do not pass into pancreatic juice,is justified at this stage. In desperate circumstancesa jejunostomy to feed the patient may be life-saving,though in Sinclair’s patient glucose given directly intothe jejunum by tube stimulated the flow of pancreaticjuice.Should an external fistula follow, this will usually close

spontaneously ; and meanwhile conservative treatmentis directed towards protecting the skin from digestion,maintaining fluid and electrolyte balance, and if necessaryreplacing lost pancreatic enzymes. It is doubtful whethermeasures usually recommended to depress the externalpancreatic secretion, in order to encourage the fistula toclose, are of much value.4 When food is taken by moutha bland mixed diet is probably best, since fat and proteinproduce less pancreatic juice than carbohydrate. Ephe-drine, atropine, and propantheline (’ Probanthine ’) haveall been recommended to reduce the volume of secretion.Conservative measures should be persisted in for severalmonths ; but if the fistula has not closed after sixmonths, or if closure leads to pain, v-omiting, or cystformation, then operation should be considered. The

Lahey operation,5 which consists in implanting thefistulous track into the jejunum, occasionally failsbecause the fistulous duct, having no epithelium, closesand pancreatic cysts form. In these rare circumstancessome other manoeuvre, such as excision of the distal partof the pancreas together with the origin of the fistula,6 7may be necessary. A possible alternative is a retrogradeor caudal pancreatico-jejunostomy, as performed byDuVal 8 in cases of chronic relapsing pancreatitis.

CUTANEOUS URETEROSTOMY

URINARY diversion by implanting the divided endsof the ureters into the abdominal wall has never beenwidely favoured, for it requires a urinary collectingapparatus. On the other hand, with this method thereis less risk of biochemical imbalance and ascendingpyelonephritis than with ureterosigmoidostomy; andin certain cases, particularly where only one functioningkidney remains, its adoption may be advisable. Standardtechniques, however, commonly involve an indwellingureteral catheter, which may predispose to the veryhazard that the method is supposed to avert-namely,stenosis of the ureteral stump and retrograde sepsis.McDonald and Heckel 9 now describe a plastic procedureby means of which long-continued catheterisation isavoided and the incidence of stricture reduced. Brieflythe operation consists in splitting the end of the dividedureter and embedding each half subcutaneously intotwo infolded skin flaps cut from the margins of the mainincision. Subsequent retraction of the skin flaps during

healing maintains the patency of the ureteral orifice,and indwelling catheters can then be dispensed with.Satisfactory results are claimed in 13 cases out of 22

operated on during the past eighteen years. Although thistechnique does not entirely eliminate the risks andinconveniences of cutaneous ureterostomy, because ofits simplicity it has much to recommend it.

1. Lancet, Jan. 5, 1957, p. 31.2. Pickering, G. W. Ibid, p. 1.3. Brit. med. J. 1955, i, 555.4. Sanjivi, K. S. Lancet, Feb. 2, 1957, p. 267 ; Ibid, March 16,

1957, p. 589.5. Rambling, J. Ibid. Feb. 16, 1957, p. 372.

CONTROLLED TRIALS NEEDED

SOME of us are concerned because the rate of theincrease in true knowledge in medicine seems slow inrelation to the immense amount of work done. It may bethat, as science progresses, more effort must be expendedto achieve a commensurate advance. But too often resultsare obtained whose worth is small-though much time,thought, and money has been used up-because they arebased on too small a series of observations. Thus on

many topics a great mass of information has beencollected which cannot be integrated because the con-ditions under which it was collected varied so much.When a subject is being tackled for the first time, manysmall-scale- experiments are needed to get a general ideaof what is involved ; but once this stage is over, largecontrolled experiments are often needed to test the hypo-theses that have arisen. We have called for a certainreturn to planning in our professional affairs,’- and moreplanning in experimental clinical medicine would bewelcome. -

An example is the treatment of high blood-pressure.Professor Pickering 2 lately contrasted our ignorance(after twenty years’ experience) of how useful is

sympathectomy for hypertension, with our sure knowledgeof the place of drugs in tuberculosis-for there have beenfew controlled trials of sympathectomy. We do notcertainly know whether surgery benefits hypertensives(except in very severe cases), much less whichoperation is most beneficial. With the hypotensive drugs,which have been the subject of so much investigation,the position is likely to be little better until a big trial ismade with all the major variables controlled. No one

group of physicians could expect to see enough cases toconduct such a trial : but if a large number of workerscould be persuaded to treat patients in a controlledfashion as part of a prearranged plan, we might gainreliable evidence as to which drugs are indicated for whichpatients, and when other treatments (e.g., dietary orsurgical) are needed. That such cooperative schemescan be successful is obvious from many reports of theMedical Research Council, and from such joint efforts asAnglo-American investigation of the treatment ofrheumatic fever.3 -

Professor Sanjivi 4 has proposed that patients withhypertension but no symptoms should be treated withdrugs in an attempt to keep the blood-pressure normal,and has given an account of some of his patients treated(without controls) with reserpine. Dr. Rambling 5

expressed the misgivings that many doctors will feel,especially in view of the side-effects of such drugs :and in our correspondence columns this week Dr.Muhammad takes the view that Professor Sanjivi’spatients would have done equally well with reassuranceand sedation. But the simple fact is that we do notknow whether or not they would have done as well ;and the only way to decide the very important questionof whether or not active hypotensive treatment is worthwhile is to begin a controlled trial, treating some patientswith drugs designed to lower the blood-pressure andothers with reassurance and mild sedation. This would

1234

1. Burroughs, J. T., Kirklin, J. W. Proc. Mayo Clin. 1956, 31, 182.2. Swan, H. J. C., Toscano-Barboza, E., Wood, E. H. Ibid, p. 177.3. Mustard, W. T. Arch. Dis. Childh. 1957, 32, 1.4. Snellen, H. A., Albers, F. H. Circulation, 1952, 6, 801.5. Burchell, H. B. Proc. Mayo Clin. 1956, 31, 161.

take many years, though preliminary results would beto hand sooner. Treating a small number of patients withtransient hypertension, without using controls, will tellus little.

Many other conditions call for similarly controlled

study. Since living organisms contain so many variables,biological science is bound to be less exact than physicalscience. But one way in which the investigator of livingcreatures can approach exactitude is by observing a lotof them. This is not to say that large collective studiescan wholly replace individual investigations : the giftedresearch-worker will always be needed to point the way,and the worker who studies a few patients in great detailmay provide information (e.g., on individual variationsand on side-effects) which would be missed in a largestudy designed to answer specific questions.

ANOMALOUS PULMONARY VENOUS DRAINAGE

IN early foetal life the venous drainage of the lungsis through the umbilico-vitelline system which connectswith the systemic pre- and post-cardinal veins. The

precardinal veins unite to form the right superior venacava, and the postcardinal veins unite to form theinferior vena cava. At the same time the sino-atrialregion of the primitive heart tube is forming a localisedpouch which becomes the left atrium, and from this achannel extends towards the lungs and finally connectswith them to become the common pulmonary vein.As this is dividing into the four pulmonary veins, themore primitive umbilico-vitelline system is absorbed.

Total anomalous pulmonary venous drainage in post-natal life results from the retention of the early stage ofdevelopment with failure of the heart to make connectionwith the lungs by the common pulmonary vein. In the

majority of patients the venous drainage from the lungsenters a persistent left superior vena cava by a commonchannel and thus connects with the right atrium. Less

commonly the pulmonary veins drain directly into theright atrium or via the coronary sinus, inferior vena

cava, portal vein, or a persistent ductus venosus.1For life to be possible there must obviously be a right-to-left shunt, and this is usually through the atrial

septum by means of a patent foramen ovale or an atrialseptal defect. Part of the mixed venous return to the

right atrium will then pass into the left atrium, andpart will go through the tricuspid valve into the rightventricle. The pulmonary and systemic venous returnsare not completely mixed in the right atrium, and thepulmonary stream entering through the superior venacava tends to be directed through the tricuspid valveinto the right ventricle, whereas systemic venous bloodfrom the inferior vena cava tends to go through theforamen ovale into the systemic arterial circulation.For this reason pulmonary arterial blood may show anoxygen saturation which is as high as or even higherthan that in the systemic arterial blood.2The incidence of total anomalous pulmonary venous

drainage is greater than was previously appreciated ;it accounts for about 2% of all congenital heart lesions.3Survival into adult life has been reported with increasingfrequency,2 4 but the disorder is of greatest importancein infancy because 80% of those affected die before1 year of age.5In adults the condition clinically resembles simple

atrial septal defect, from which it may be indistinguish-able except by. radiography or cardiac catheterisationand dye-dilution studies.2 In infants the condition

may be even more difficult to diagnose. Mild cyanosisis often present in later life ; but it is seldom obvious

in the first six months, even though the systemic arterialblood is somewhat unsaturated. The heart is usuallyof normal size at birth, but enlarges rapidly in the firstfew months of life. A systolic murmur is often heardat the left sternal border and is thought to be due toincreased blood-flow through the pulmonary artery;occasionally over the base of the heart there is a venoushum, which probably originates from the abnormal

pulmonary venous return.6 The second heart soundin the pulmonary area is split, and in about a

third of cases is accentuated owing to a loud pul-monary component associated with pulmonary hyper-tension. Radiographically the heart often shows a

characteristic" figure-of-8" or " cottage-loaf appear-ance owing to persistence of the left superior venacava with enlargement of the right atrium and rightventricle ; the pulmonary artery is increased in sizeand activity and the peripheral vascular markings arealso increased. The electrocardiogram shows evidenceof right ventricular and right auricular hypertrophy.The diagnosis is made from the high oxygen satura-

tion in blood from the superior vena cava or highright atrium and from the unusual finding thatpulmonary-arterial blood is as highly oxygenated as

systemic-arterial blood.Of 30 cases reported by Gott et al. the majority

died in the first three months of life and only 3 wereliving and past infancy. Of the 30, several had severesymptoms, and 4 were submitted to operation. Mostworkers believe that, if there is not severe pulmonaryhypertension with pronounced reversal of blood-nowthrough the inter-atrial communication, surgical correc-tion should be attempted. Operation with the aid of anextracorporeal circulation to by-pass the pulmonarycirculation, or with hypothermia, has sometimes provedsuccessful, even when undertaken in infants. The

operation consists in anastomosing the common venouschannel carrying the pulmonary venous return to theleft atrial appendage, the atrial septal defect beingleft unclosed. 8 In three different series 3 out of 4 patients 13 out of 6 and 4 out of 12 3 survived. Total anomalouspulmonary venous drainage must therefore take its

place beside other congenital malformations of the heartand great vessels carrying a grave prognosis in early life,which may now be amenable to surgical treatmei.t.

6. Du Shane, J. W. Ibid, p. 167.7. Gott, V. L., Lester, R. G., Lillehei, C. W., Varco, R. L. Circula-

tion, 1956, 13, 543.8. Mustard, W. T., Dolan, F. G. Ann. Surg. 1957, 145, 379.

INTERNATIONAL FEDERATION OF SURGICALCOLLEGES

AT a meeting representative of surgical colleges in manycountries, held at the Royal College of Surgeons of

England, with Sir Harry Platt, the president, in the chair,it was unanimously agreed to found an internationalfederation, and the inaugural meeting is to be held atStockholm in July, 1958. The object of the federationwill be the maintenance and improvement of thestandards of surgery throughout the world. The memberswill not be individual surgeons, but such national surgicalinstitutions as may be elected to membership.The bodies represented at the preliminary meeting

were the Royal College of Surgeons of England, AmericanCollege of Surgeons, Royal College of Surgeons of Edin-burgh, Royal College of Surgeons in Ireland, RoyalFaculty of Physicians and Surgeons of Glasgow, RoyalAustralasian College of Surgeons, Royal College of

Physicians and Surgeons of Canada, Académie deChirurgie de Paris, Belgian Surgical Society, RoyalCollege of University Surgeons of Denmark, DutchAssociation of Surgeons, Italian Society of Surgery.Norwegian Surgical Society, and Swedish SurgicalAssociation.