32

thus be possible to ascertain which categories of patientmost need convalescence and to what extent their needsare met. Other agencies sending patients for con-

valescence or recuperative holidays include countyhealth authorities, friendly societies, and large businessfirms ; and a selection of these, too, are being asked tostate their needs and to say how far they are satisfied.At the same time a study is to be made of those actuallyreaching convalescent homes. A large number of homeswill be asked how-many patients they receive over agiven period, and into what categories they fall. Theanswers should show how many patients get intoconvalescent homes, where they come from, and what istheir state of health on admission.

It should be possible to complete a reasonably accuratesurvey within a year, and the Fund will then be able toissue a report for the guidance of those whose duty it isto maintain homes. It will also go on helping to establishnew homes by making grants of money. Thanks

largely to its financial help, several homes have been setup already to take the types of case for which accom-modation is scarce. The most notable of these are

perhaps Capesthorne, at Mudeford, which is run by theRed Cross for babies under the age of 2, and a smallhome for epileptics at Fairwarp in Sussex, run by theNational Association for Mental Health. The Fund isalso giving support to a new home for epileptics, shortlyto be opened by the N.A.M.H. at Saxmundham, and toa new wing of the Dedisham Convalescent NurserySchool for children under 5. These are a beginning, butbefore any large programme can be planned it is essentialto know accurately what types of home are most needed.This the survey should reveal.

CARCINOMA AS A SEQUEL TO ULCERATIVECOLITIS

ONE of the most serious complications of ulcerativecolitis is carcinoma of the colon or rectum. This is

certainly rare, though the incidence varies widely indifferent series. Johnson and Orr put the figure atabout 25%. - The highest incidence is recorded byJackman and colleagues 2 in 95 patients who developedulcerative colitis before the age of 16 years ; 6-5%-of these children developed carcinomas of the largebowel in later life. The duration of symptoms ofulcerative colitis before the carcinoma is diagnosed variesin the reported cases from 3 months to 36 years ; the

average duration has been given by Cattell and Sachs 3as 9 years. In patients with ulcerative colitis, carcinomasof the colon and rectum seem to arise, on average, atan earlier age than in the general run of patients. ThusJohnson and Orr found that in 40 recorded cases ofcarcinoma complicating ulcerative colitis the averageage at onset was 40-2 years, compared with 53 years inother cases of carcinoma coli. -

A much more common complication of ulcerativecolitis is the formation of polypi, which are seen in10-16% of most series. They arise in severe cases duringthe healing phases and are most numerous in the rectum,getting less frequent higher up. They have some-

times been observed in the lower part of the ileum.In view of the known tendency of intestinal polypito become malignant, it is sometimes suggested that theyare the precursors of carcinoma in patients with ulcerativecolitis. In considering this question the pathology of thepolypi must be clearly understood. Most of them areinflammatory in origin and consist of oedematous hyper-trophic areas of mucosa which have escaped the destruc-tion suffered by the surrounding- areas. Microscopically,1. Johnson, T. M., Orr, T. G. Amer. J. digest Dis. 1948, 15, 21.2. Jackman, R. J., Bargen, J., Helmholtz, H. F. Amer. J. Dis.

Child. 1940, 59, 459.3. Cattell, R. B., Sachs, E. J. Amer. med. Ass. 1948, 137, 929.

beneath a generally intact layer of lining epithelialcells the tissues are infiltrated with inflammatory cellswith an increase of fibrous tissue. Some of the glandsmay become blocked, leading to retention of mucus and-the formation of cysts. These so-called pseudoadenoma-tous polypi must be distinguished from true adenomatouspolypi. The adenomatous type is occasionally found inpatients with ulcerative colitis and may become malignant.But Felson and Wolarsky 4 have found that out of 955patients of varying ages who came to necropsy, excludingcases of ulcerative colitis, 6.4% had two or more adenonia-tous polypi in the colon. (This does not include the rarerhereditary adenomatosis coli, in which the whole colonis studded with multiple adenomas.) The incidence ofadenoma in their patients with ulcerative colitis waswell below this figure. Polypi of the pseudoadenomatoustype were seen in 134 (15-7%) of their 855 patients withulcerative colitis. In no case did they note any tendencyfor the polypi to become malignant. These findingsmust be taken as evidence against the polyposis ofulcerative colitis being a pre-malignant condition ; rand it must be concluded that the presence of such

polypi is not an indication for colectomy.

THE LIVER LOBULE IN PERSPECTIVE

FOR a century misconception of the histologicalstructure of the liver has been copied from textbook totextbook (with a few exceptions) ; and this despite theembryological studies of the latter half of the century andthe more recent large volume of experimental work onthe aetiology of hepatic cirrhosis. The picture familiarto all-the liver lobule composed of anastomosing cordsor columns of cells radially arranged around the centralvein-was conceived by Gerlach in 1849, developedchiefly by Beale (1856, 1889), and supported by Pfliiger(1869) ; the description, analysis, and reassertions ofHering (1866, 1872) on the geometric three-dimensionalaspect were almost completely ignored. So a good manymodern textbooks still give only the one-dimensionalaccount.

It was the preparation of a stereoscopic filmstrip onthe histology of the liver for anatomy students thatstimulated Elias 5 two re-examine the structure of the liverlobule. Having completed stereograms of liver lobuleshe wanted to add photographs of wax-plate reconstruc-tion models and also some photomicrographs. When hecame to examine sections of the human liver made

perpendicularly to the central lobular vein he noted thatlong rows of cells were invariably seen and were unac-countably numerous. For he reasoned that if there weretortuous but linear columns arranged radially about thecentral vein, the chances of the microtome cutting themlengthwise for any considerable distance would be veryslight ; most of them would be cut obliquely and wouldbe about three to four cells long. -Further, it was almostimpossible to find cross-sections of cords, which shouldbe very numerous in tangential sections of the lobule.In man and the cat, sections parallel to the central veinshowed long rows of cells simulating cords, and, no matterhow the human or cat liver was cut, long linear rows ofcells were always seen, with, at wide intervals, smallisolated groups of cells in an epithelial arrangement.Elias concluded that this appearance in sections couldonly be produced by curved plates, sheets, or laminae,one cell thick. This was verified by making wax-platereconstruction models and by examining thick unstainedsections mounted in glycerin.

z

-

Thus the new concept is that the hepatic cell-platesare curved and perforated at short intervals to permitthe passage of the sinusoids which run towards thecentral vein ; the cell-plates -have unicellular and some-

4. Felson, J., Wolarsky, W. Arch. intern. Med. 1949, 84, 293.5. Elias, H. Science, 1949, 110, 470.

33

times bicellular bridges, and it is these which accountfor the appearance of cords on cross-section. The human

hepatic lobule therefore consists of a continuous tissueof connected walls, which enclose the spaces for thesinusoids to run through. The polygonal meshwork ofbile-capillaries runs between the cells in the plates andbridges, and it forms hexagonal intercellular and peri-cellular networks within the liver plates. This is in close’accord with the easily demonstrable network commonlyseen in sections, which fits poorly into the hithertoconventional picture. Since in man and the cat the

spaces formed for the sinusoids between the plates arelike long sacks, their type of liver may be regarded as" saccular," in contrast to the " tubular " type of liverof the horse and rabbit, in which the spaces between thehepatic laminae are narrow and cylindrical.

NEW CONCEPTIONS IN HIRSCHSPRUNG’S

DISEASE

ANOTHER year’s work on Hirschsprung’s diseasehere and in the U.S.A. has confirmed the views on its

pathology and treatment which Dr. Bodian and his

colleagues at the Hospital for Sick Children, GreatOrmond Street, set out in their paper of January, 1949.At that time clinical evidence had placed the site ofintestinal obstruction in a narrow

" spastic " segmentdistal to the dilated hypertrophied colon. A careful

radiological technique had been developed to displaythe terminal narrow segment and to obviate the floodingof the lower colon with barium which produces a fallaciousappearance of dilatation to the anus. Resection of thisabnormal distal segment by rectosigmoidectomy hadbeen reported, first by Swenson,2 of Boston, to the

Society of University Surgeons at New Orleans, and thenby Stephens,3 one of the Great Ormond Street team,to the surgical section of the Royal Society of Medicine.Histological examination of the distal segment byBodian in 15 cases had revealed an absence of intramural

ganglion cells and the presence of abnormal nerve-trunksat the sites of Auerbach’s and Meissner’s plexuses.

Early in 1949, Whitehouse and Kernohan 4 published apathological report on 11 cases of Hirschsprung’s diseasefrom the Mayo Clinic ; 10 of the specimens were obtainedat necropsy and 1 after subtotal colectomy ; 8 of the

patients were children aged 8 months to 15 years, and3 were adults. The histological findings were essentiallythe same as those reported by Bodian et al. During1949 Swenson and his collaborators 5 amplified theirformer clinical and radiological reports by a study ofcolonic peristalsis in 8 cases of Hirschsprung’s disease,using a multiple balloon technique, and by a histo-

logical study of - 7 specimens. They also reported ona total of 34 rectosigmoidectomy operations. Theirphysiological experiments proved that peristalsis isabsent and tonus increased in the distal colonic segment,and they confirmed that there are no sympathetic ganglioncells in this part of the gut. Their follow-up results forperiods up to two years were apparent cures in 33 casesand 1 postoperative death. Radiologically they_de -mon-strated return of the colon to approximately normalafter operation.

In this issue (p. 19) Dr. Bodian, Mr. Stephens, andDr. Ward bring their findings and results up to date.The number of children with Hirschsprung’s diseasetreated by rectosigmoidectomy at the Hospital forSick Children is now 26, and the 12 cases which wereformerly reported have now been observed for twelve1. Bodian, M., Stephens, F. D., Ward, B. C. H. Lancet, 1949,i, 6.

2. Swenson, O., Bill, A. H. Surgery, 1948, 24, 212.3. Stephens, F. D. Proc. R. Soc. Med. 1948, 41, 831.4. Whitehouse, F. R., Kernohan, J. W. Arch. intern. Med. 1949,

82, 75.5. Swenson, O., Rheinlander, H. F., Diamond, I. New Engl. J. Med.

1949, 241, 551.

to fifteen months. This is still too short a time toreveal the final effects of the treatment, but the clinicalimprovement in the children, the establishment of

regular spontaneous bowel actions, and the strikingregression of radiological appearances after operationare impressive. The histological findings previouslydescribed have now been established in 28 consecutivecases ; there can be no reasonable doubt that they are .

characteristic of Hirschsprung’s disease and that absentperistaltic movement and increased tone in the distalcolonic segment are functional manifestations of thesestructural changes. On the basis of the new aetiologicalconcept rectosigmoidectomy is a rational treatment,and its value is certainly supported by the results so farobtained.

NOTIFICATION OF INFECTIOUS DISEASES

THE classification of notifiable diseases of the centralnervous system has now been placed on a more realisticbasis. By new regulations, which we outlined last week,the distinction of polioencephalitis from poliomyelitishas been brought to an end ; and poliomyelitis is nownotifiable as paralytic

" or

"

non-paralytic." " Acute

encephalitis " (" infective " or "

post-infectious ")replaces the former heading of " encephalitis lethargica " ;and the more generic

" menirrgococcal infection "

supersedes " cerebrospinal fever." The regulations arediscussed in our public-health columns this week.

NEW YEAR HONOURS

Dr. Haden Guest, who receives a peerage, enteredParliament first in 1923 and is chairman both of theHouse of Commons Medical Parliamentary Groupand of the Medical Personnel (Priority) Committee.He founded the Labour Party’s Commonwealth Group,and the breadth and vitalitv of his interests have like-wise been shown by contributions to our columns asa special correspondent abroad in war and peace, aswell as by regular parliamentary notes from " Medicus,over many years. - We thus have special reasonto be glad at this recognition of his public services andpersonal merits. The knighthood in the Royal VictorianOrder bestowed on Dr. H. K. Graham-Hodgson, of theMiddlesex Hospital, is a suitable promotion from thec.v.o. he received as the radiological member of theteam who attended King George V in his illness of 1928.Mr. T. E. V. Hurley, who becomes K.B.E., is consultingsurgeon to the Royal Melbourne -Hospital, and of thenew knights bachelor two (Dr. F. A. Gunasekera, of

Ceylon, and Mr. T. G. Wilson, of Adelaide) are dis-

tinguished members of our profession overseas. Athome it is a pleasure to see the name of Dr. H. E. A-Boldero, dean of the Middlesex Hospital medical schooland registrar of the Royal College of Physicians, whosewisdom in counsel has been decisive so much more oftenthan his modest demeanour would suggest. Dr. J. A.Charles, who will next May succeed Sir Wilson Jamesonas chief medical officer of the Ministry of Health, isanother quietly effective man, whose ability was evidentwhen he was -medical officer of health for Newcastle

upon Tyne, and who, as a deputy c.M.o. at the Ministry,has won confidence by his readiness to listen and hispower to understand. Our colleagues in NorthernIreland will especially welcome the honour paid toDr. W. W. D. Thomson, professor of medicine at Queen’sUniversity since 1923, and one of those who have helpedto make Belfast the outstanding school it is today.These and the other names on a good list appear in

full on another page. Outside the Medical Register,one of the highest honours, the G.c.B., goes to Sir WilliamDouglas, secretary to -the Ministry of Health during itsdifficult labours of the past few years, and- a knighthoodto Mr. Arthur Sims, benefactor of medicine and surgerythrough his Commonwealth travelling professorships.