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subjects no comparable hypoglycaemia is observed.The blood-sugar of patients with a normal blood-

sugar curve may fall as low as 55 mg. per 100 ml.11/2-2 hours’ after glucose, without symptoms. 5It should not be forgotten that the actual blood-

sugar level is only one of the factors determiningthe onset of hypoglycaemic symptoms ; the rate offall and extent of fall are among the other factors.

The data on which to base the answer to the secondproblem are still conflicting. BARNES has establisheda fairly direct time-relationship between the hypo-glyceemia and the occurrence of symptoms in his

patients, but in GILBERT and DUNLOP’S 2 series thetime-relationship is not so clear ; in both the cases

they record in detail symptoms coincided with theperiod of hyperglycsemia and not with that of hypo-glycsemia. On the basis of their findings in 14 cases,ADLERSBERG and HAMMERSCHLAG 6 subdivide the"

postgastrectomy syndrome," as they call it, into

early and late postprandial types. The early type,which is relieved, partially at least, by rest in thehorizontal position and small frequent meals (andwhich presumably corresponds to the" dumping "syndrome of some writers), they attribute tomechanical factors : these are the small stomach,the rapid emptying of the stump, the rapid fillingand emptying of the jejunum, and the subsequentmesenteric irritation. The late type, which is relievedby the ingestion of food, they attribute to hypo-glycsemia. This classification is not accepted byGILBERT and DUNLOP, who argue that hypoglycsemiaexplains the whole syndrome. Yet another hypo-thesis is that of GLAESSNER,7 who attributes the

early postprandial symptoms to hyperglycsemia ;but there is little evidence that hyperglycaemia perse can produce the characteristic upper abdominaldiscomfort and occasional vomiting.Much further work is clearly required to elucidate

the cause of this syndrome. It should also be possibleto establish exactly how often the complication arisesand how it is best avoided. No systematic study ofthis sort has yet been recorded, but observation of thesyndrome after 17 out of 45 consecutive gastrectomies 2suggests that the incidence is by no means negligible.On the question of prophylaxis, opinion is divided.Thus in BARNES’S series, when the retrocolic Polyaanastomosis was abandoned in favour of a modifiedHofmeister type of anastomosis, no further case wasnoted after over a hundred operations. GILBERT andDuNLOP, on the other hand, concluded that therewas nothing to choose between these two procedures.On the treatment of the established syndromethere is greater unanimity.’ The usual procedure isto give a high-fat, low-carbohydrate diet, or alter-

natively to give 1 oz. of olive oil before meals. GILBERTand DuNLOP recommend also six small meals dailyinstead of three larger ones, and they have found thatephedrine gr. 1/2 half an hour before the three mainmeals is of value. Sometimes the condition tends to

improve as time goes on. Whether, as ADLERSBERGand HAMMERSCHLAG suggest, there is a psycho-neurotic element in the condition is one of the manvunsolved riddles in this intriguing complication ofmodern gastric surgery.

5. Lawrence, R. D. Brit. med. J. Sept. 20, 1947, p. 470.6. Adlersberg, D., Hammerschlag, E. Surgery, 1947, 21, 720.7. Glaessner, C. L. Rev. Gastroenterol. 1940, 7, 528.

Annotations

CONVALESCENT HOMES IN THE NATIONALHEALTH SERVICE

THE position of convalescent homes in the NationalHealth Service has been in doubt-will they be taken overby the Ministry of Health, like hospitals, or left outside IThe Ministry’s policy seems to be to indicate whichhomes could legally be included in the service, and toleave the regional boards to make the final selection.The Ministry has now sent each board a list of homesdivided into those " apparently liable " to be transferredto the service, and those whose fate is still under investiga-tion. The former homes may, if they choose, apply tobe disclaimed.

It is not obvious from the list what principle is beingfollowed in making this distinction. Some of the"

apparently liable " homes give no treatment, and, onthe precedent of the homes owned by the Birmingham.Hospitals Saturday Fund, would not be liable. The

Ministry is at a disadvantage in not being able to visitall the homes, and about many of them only sketchyinformation is available. The regional boards havenine months to decide which homes to disclaim, and it isto be hoped that no decision will be made without a visit.

It is noticeable that the homes which came underthe Ministry of Education by the Education Act of 1944are left alone, except for the few which are long-termchildren’s hospitals in all but name. There is a risk that,merely because they have school-teachers on their staffs,these homes, which are primarily for convalescents, willbe excluded from medical supervision, since the Ministryof Education inspectors, on their rather infrequent visits,are concerned only with the educational aspect.

SECOND ATTACKS OF POLIOMYELITIS

IT is commonly assumed that an attack of poliomye-litis with paralysis confers a life-long immunity. In1930 Still noted that what appeared to be secondattacks of the acute disease were occasionally reported,but he regarded many of them, occurring within fourmonths of the initial illness, as recrudescences of the

original infection to be distinguished from true secondattacks due to reinfection, which were distinctlyrare. Still found that between four months andtwo years after the first attack there was an interval

during which second attacks had never been recorded,and he therefore postulated about two years as the

probable maximum duration of the immunity resultingfrom an acute attack. Of the 2 cases recorded byColonel Lipscomb in his letter in this issue, in one thesecond illness occurred about four months after the initialattack and may possibly have been a recrudescence ;in the other the second attack was separated from thefirst by nine years and reinfection is probable. In 1938Fischer and Stillerman 3 collected 13 authentic instancesof second attacks arising two to twenty-four yearsafter the first. They added a further 4 examplesobserved during the 1935 outbreak in New York. After

making a statistical study of this outbreak and con-

sidering the available data they concluded that the

admittedly very low rate of incidence of second attackswas not evidence that any immunity was necessarilyconferred by an attack of poliomyelitis. In 1936

AVildtgrube 4 made the interesting observation that in

only 1 of 13 cases recorded as having two separateattacks did the second paralyse muscles which had beenaffected in the first.

Monkeys which had recovered from one experimentalinfection with poliomyelitis were shown by Flexner 5 two1. See Lancet, Sept. 20, p. 431.2. Still, G. F. Arch. Dis. Childh. 1930, 5, 295.3. Fischer, A. E., Stillerman, M. J. Amer. med. Ass. 1938, 110, 569.4. Wildtgrube, F. Mschr. Kinderheilk. 1936, 66, 265.5. Flexner, S. J. exp. Med. 1937, 65, 497.

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be readily reinfected by the virus used on the first

occasion, as well as by different material. Other experi-mental work of this kind by Toomey 6 indicates howeverthat sublethal infection with certain virulent strains ofvirus will protect monkeys against subsequent attemptsto infect them with other presumably less virulentstrains. Among the puzzling results of human sero-

logical investigations in poliomyelitis are the not uncom-mon failure to find protective antibodies in the serumof convalescents, and the frequent observation of suchantibodies in the sera of older persons who have nothad an obvious clinical attack. Some of these findingsmay be explained by antigenic differences betweenvarious strains of the virus. It seems probable thatthere is a poliomyelitis group of viruses within whichthere are immunological variations, not unlike thosefound in the group which cause human influenza. Thesolution in the laboratory or elsewhere of these problemswould contribute a great deal towards a better under-standing of the epidemiology of the human disease.

CHOLERA IN EGYPT

THE cholera which has broken out in Egypt duringthe last few weeks concerns all nations engaged inmaritime trade to the west of the Suez canal. The reportof the UNRRA Health Division 7 on the cholera situationduring the summer of 1946 deplored the paucity ofinformation about the prevalence of the disease through-out the Far East, but remarked that " there has beenno case of cholera west of India since 1931, apart fromthe Afghanistan-Iran outbreak of 1938-39." The well-known tendency of cholera to spread along trade andpilgrim routes was largely checked for many years,but during the late war its incidence in the Easternoccupied countries rose sharply, and there were con-siderable outbreaks in areas previously free for manyvears. In 1946 there was one of the most extensiveoutbreaks ever recorded in China and the Far East.

Cholera’s home is India, more particularly in theareas of Bengal, Madras, and Bombay. Epidemics furtherafield, such as those in the larger seaports of this countryshortly after the middle of the last century, have beenavoided as a result of efficient quarantine and control.An important factor in Indian epidemics has been themass movement of pilgrims to the innumerable fairs andreligious festivals. Under suitable climatic conditionsthere is grave danger of outbreaks in pilgrim camps ;but, still worse, the movements of pilgrims are responsiblefor the carriage of infection to fresh communities, some-times overseas. The migration of large numbers of

refugees, such as that taking place in India at present,has almost invariably been associated with devastatingepidemics of cholera, and these are aggravated bymalnutrition and physical hardship. The pilgrim trafficfrom the Mohammedan countries to Mecca, possibly morethan any other agency, has disseminated the diseasefrom its natural home, and it is possible that the infectionhas been conveyed by this means to Egypt. Althoughthe Egyptian epidemic has received much publicity-we are informed that about 100 new cases are found daily-it cannot be compared in magnitude to the greatoutbreaks which, unfortunately, are commonplace inIndia and in China. With the bottle-neck of the Suezcanal between the eastern and western worlds, however,the strategic importance of Egypt in public health isobvious. The climate at certain times, and the densepopulation living under insanitary conditions in the Nilebasin must render the appearance of cholera there asource of constant appre.hension. It is indeed somewhat

surprising to find that the last important epidemicoccurred some sixty years ago ; the successful blocking6. Toomey, J. A. J. Immunol. 1938, 35, 1.7. Stowman, K. Cholera Situation, Summer, 1946. UNRRA Epid.

Inf. Bull. 1946, 2, no. 16.

of the westward spread of cholera from the highlyendemic foci of India and China westwards has been nomean achievement in public health. What course the

present epidemic may take remains to be seen. Theconcentration of the resources of the Western world in

combating the outbreak is likely to ensure its earlylimitation and ultimate elimination, more particularlysince the infection really flourishes only in more tropicalclimates ; in temperate and subtropical countries ittends to be self-limiting.Treatment is still unsatisfactory, for there is no specific

cure for the established infection ; repair of the grossfluid and mineral loss, on a physiological basis, remainsthe foundation of hopes for recovery in severe cases.The sulphonamide drugs, either those feebly absorbed,such as succinyl, sulphathiazole, or sulphaguanidine, orof those freely absorbed, such as sulphadiazine or sulpha-mezathine, are not curative as they are, for example,in the bacillary dysenteries. Nevertheless, in substantialdosage they appear to shorten the course of cholera andpossibly modify its severity. Prophylactic immunisationwith cholera vaccine is a contributory means of personalprophylaxis ; but the duration of what protection itaffords is brief, and so it must be given at frequentintervals throughout the period of risk. The controlof an epidemic rests fundamentally on prompt andefficient segregation of all suspected cases and contacts,and on efficient sterilisation of their highly infected

discharges. The rigid protection of all water and food-supplies from possible contamination with, infected faecalmaterial-the ultimate source of infection in every epi-demic-is obviously of major importance. From Cairocomes news that the city and its suburbs are beingsprayed with D.D.T. in an attempt to reduce the numberof flies.

CONGENITAL AORTIC COARCTATION

ON Sept. 26 Prof. Alfred Blalock, of Baltimore,delivered a Moynihan lecture at the Royal College ofSurgeons to an audience of well over a thousand. Forthose who could not find a place in the lecture-hallhe gave a further demonstration immediately afterwards.The address was on congenital cardiovascular defects,but was mainly concerned with aortic coarctation.

Before Dr. Blalock began operating for coarctationof the aorta a considerable amount of experimental workhad to be done to see how the stricture in the aorta couldbe by-passed and an adequate blood-flow provided to thedescending aorta below the narrowing. It was foundin dogs that if the aorta was divided the left subclavianartery could be turned downwards and joined to thedistal segment in such a, way that a normal circulationwas maintained. An alternative method of dealing withthe coarctation was introduced by Crafoord, who actuallyresected the stenosed area and performed an end-to-endanastomosis between the divided ends of the aorta.This is the method which Dr. Blalock has followed on11 occasions. He showed a cinematograph film of theoperation which also demonstrated the essential clinicalfeatures of the condition.The patient was a young woman in whom the raised

blood-pressure in the arms and reduced tension in thelegs was clearly illustrated, as also the enlarged super-ficial collateral vessels. Radiographically the notchingof ribs due to pressure erosion from tortuous and dilatedintercostal arteries was well marked. The approachwas made through a left posterolateral thorectomywith resection of a length of the 5th and back ends of the4th and 6th ribs. As might be expected from the presenceof collateral channels, there was considerable bleedingduring incision through the chest wall. The lung wasthen displaced and the aorta identified. The coarctationwas well defined not only by a narrowing but by anarea where the violent pulsation of the aortic arch and