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non-activation of leaves exposed to sunlight remainsa mystery, but the possibility exists that the over-whelming preponderance of vitamin A in green leaves,under the conditions of the experiment, somehowmasks the presence of a small amount of vitamin D,perhaps because the growth produced in the experi-mental animals, receiving the green leaves, is muchgreater than the growth of the controls. A smalldegree of antirachitic activity has been detectedin green alfalfa by H. Steenbock and co-workers(1922), by W. G. Gaessler and A. C. McCandlish (1923),and by E. V. McCollum and his co-workers (1924).It must, however, be concluded that the antirachiticvalue of green food is usually very slight, and in noway comparable with its richness in vitamin A, as-as was at one time supposed.The same misconception as applies to terrestrial

green food also exists with regard to the green foodof the sea. It used to be held that the codfish obtainsthe vitamin D, in which its liver oil is so rich, from itsfood and that the ultimate source of vitamin D for.all organisms in the ocean is in the green algae and.diatoms which inhabit it. These, it was believed, formtheir vitamin D under the influence of direct insolation.It had been shown by H. L. Jameson, J. C. Drummond,and K. H. Coward 1 in 1922 that the marine diatom,Nitzschia closterium, is a rich source of vitamin A,.and confusion as to its antirachitic power came aboutin the same way as happened with terrestrial greenfood. In a paper published this year J. L. Leigh-Clare2has disposed of this comfortable theory of the originof vitamin D in the sea and has shown that Nitzschia.closterium, grown with conditions of maximuminsolation, has no antirachitic power. So we are stillleft in doubt as to which organisms provide the ivehicle by which vitamin D is supplied to the inhabi- tants of the sea. Since the green ones are notresponsible, possibly the surface baskers among theanimals play a more important part than had beensupposed, or possibly even, as C. E. Bills suggests,vitamin D can be elaborated in the body of somemarine animals, without the intervention of light.Unfortunately, however, there is still no definiteanswer to the frequent question : Where does the,cod get its vitamin D from ? "

CONTROL OF HÆMORRHAGE DURING

TONSILLECTOMY.

REMOVAL of the tonsils is perhaps the most fre-quently performed operation of surgery. Dr. WalterA. Wells, of Washington, states that in America itis almost the exception to find a person who, eitherin childhood-or adult age, has not had it performed.Although it is to be hoped that the operation willnever reach such a degree of popularity in this country—for it cannot be really necessary in so large a

proportion of the population-it is nevertheless anadvisable and beneficial procedure in a large numberof patients. The great bugbear of the operation,especially in the mind of the public, is bleeding,which usually comes on as reactionary haemorrhagea few hours after the operation. Even when the’quantity of blood lost is not enough to be alarming,it may be sufficient to retard convalescence and isdisturbing to the patient. For some time past,surgeons have been giving increased attention to theirtechnique, with a view to preventing undue bleedingduring the operation and to reducing the frequencyof reactionary hsemorrhage after it; many surgeonsnow make it part of their routine to ligature anybleeding-point which persists, even in a small degree,after sponge-pressure has been applied for a fewminutes. With this criterion most adult tonsilsrequire one or more ligatures, but they are rarelynecessary in young children ; and there is no doubtthat the adoption of such a routine materially addsto the comfort and safety of these patients. Dr.

1 Biochem. Jour., 1922, xvi., 482.2 Ibid., 1927, xxi., 368.

3 Jour. Biol. Chem., 1927, lxxii., 751.

V. K. Hart, of Statesville, N.C.,1 since tying bleeding-points during operation, encountered 14 cases of post-operative haemorrhage in 800 cases, in eight of whichfurther ligation was required. The chief reason

against the universal adoption of primary ligature isits difficulty, for it is no easy matter to tie off a vesselin the tonsillar bed in the manner ordinarily employedin more accessible wounds ; but technical difficultyis no valid excuse for non-performance, and it mayreasonably be said that no one should attempt toremove a tonsil unless he is able to ligature a bleedingvessel in its bed. The simplest method of securingthe bleeding-point is to pass a slip-knot of braidedsilk, held by a long forceps, over the haemostat afterthe method of C. G. Coakley 2 ; but this, too, requiresconsiderable practice, and many ingenious instrumentshave been designed with a view to making ligationeasier. Of these one class is a modification of thehæmostat forceps, providing a shoulder or a roundedend to enable the ligature to slip off it more readily ;others provide an arrangement by which the loop ofligature is attached to the hsemostat and carried onit into the bed of the tonsil. An instrument of thistype has been recently described by Dr. Angelo J.Smith, of Yonkers, N.Y.,3 in which a sliding rodattached to the haemostat carries the ligature at itsdistal end ; on pushing down the rod, the ligature isbrought beyond the point of the forceps into positionfor tying. Sir James Dundas-Grant achieves the sameresult by passing the slip-knot inside a metal or glasstube in the manner described in our last issue,4 whereMr. Norman Eadie also describes his device ofemploying a hole drilled through the tip of thehspmostat as a pulley. Of another type is theinstrument designed by Dr. Wells 6; it is in theform of a forceps in which a short slotted needleis fixed to the end of one blade ; on closing theinstrument over the bleeding area and openingit again, a double thread is placed through thetissues at the point required, which can then betied on the fingers in the usual way. Differentoperators will, of course, prefer different instruments,but there is no doubt that instruments which facilitatethe technique of ligature will conduce to its moreregular performance and so make bleeding aftertonsillectomy a rarer occurrence.

THROMBOSIS OF THE SPLENIC VEIN IN

CHILDHOOD.

SPLENIC anaemia is the name applied to the syn-drome of severe anaemia, accompanied by considerablesplenic enlargement, for which no clear cause such asrickets or syphilis can be found. The anaemia is of

secondary type—that is to say, the reduction ofhaemoglobin is out of proportion to the diminu-tion in the erythrocytes. The classification of suchcases is made more difficult by the fact that anaemiaand slight splenic enlargement may result from manyminor degrees of ill-health. In rare instances haemat-emesis or epistaxis are early symptoms. Cases tendto run a chronic course of from 3 to 12 years with thesupervention of cirrhosis of the liver and secondaryascites later. This latter complex constitutes Banti’sdisease. It is not clear to what extent splenic anaemiaif left to itself develops the full picture of Banti’sdisease. Removal of the spleen in the early stageshas sometimes resulted in a cure, but once cirrhosisof the liver has developed splenectomy has had noeffect. Whether the successful cases would havedeveloped into Banti’s disease later, or whether theybelonged to another type, is as yet undecided. Thesuccess of operative treatment has led to the theorythat there is primarily a morbid increase in blooddestruction by the spleen which is cured by itsremoval. Thrombosis of the splenic vein has alsobeen suggested as a cause, and in a recent monograph

1 Clinical Medicine and Surgery, August, 1927.2 Journal of Laryngology, 1924, p. 493.

3 American Journal of Surgery, July, 1927.4 THE LANCET, Oct. 8th, 1927, p. 760.

5 Medical Journal and Record, August 17th, 1927.

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Dr. Arvid Wallgren has attempted to isolate a

group of cases in which it was primary. Hedescribes in great detail his investigation of fourpatients &t the Infants’ Hospital in Goteborg, andsupplements these observations by a resume of similarcases from the literature. Apart from secondaryanaemia and splenic enlargement, his children all hadattacks of profuse haematemesis in the early stagesof the disease, these attacks bearing a definite relationto the size of the spleen, each loss of blood beingfollowed by reduction in size of the organ which thenenlarged again. In support of thrombosis, he empha-sises the following facts which he observed in hisfour cases. The vessels and parenchyma of the threespleens removed at operation were engorged withblood as though the venous circulation was obstructed.The veins of the collateral splenic circulation weregreatly enlarged. Thrombi were found in many ofthe smaller branches of the splenic vein. No actualthrombi were detected in the splenic vein itself atoperation, but the examination was necessarilycursory. In the fourth case, which died after asevere haematemesis, thrombosis of the splenic veinwas present. The effect of haematemesis on the sizeof the spleen he explains as follows. The pressureof the blood dammed back in the spleen by theobstructed vein finally becomes so great that one ofthe gastric or oesophageal branches of the collateralcirculation ruptures into the stomach, tension in thespleen is relieved by haemorrhage, and the organbecomes smaller in size. Eventually the establish-ment of an adequate collateral circulation mightprevent further haemorrhages, but extension of thethrombus would still be liable to cause further engorge-ment. The cardinal point in the diagnosis of throm-bosis of the splenic vein is the association of splenicenlargement with haematemesis early in the disease,haemorrhage being followed by a reduction in size ofthe organ and cessation by an increase. Owing tothe danger to life from repeated haematemeses andprogressive anaemia, Dr. Wallgren considers splenec-tomy the treatment of choice in these cases in spiteof its dangers. The three patients in whom thespleen was removed were quite healthy two years ormore after operation and had had no further bleeding.

This monograph brings strong evidence to showthat there is a group of cases which might have beenclassed as splenic anaemia, but which are actually dueto thrombosis in the splenic vein, and for which earlysplenectomy gives the best chance of permanenthealth. In England profuse haematemesis is a veryrare symptom in children between 2 and 11 years ofage, even in cases with splenic enlargement.

A WINTER TOUR IN SWITZERLAND.

CLIMATE is a ubiquitous study, but apart from ourown it is probable that few members even of themedical profession realise what are the precise condi-tions of the climate, physical, intellectual, social,hygienic, into which they send their patients duringthe winter. We therefore cordially welcome theopportunity offered to practitioners by the Councilof the Royal Institute of Public Health, with thecollaboration of Sir Henry Lunn, of studying climaticconditions in all the more important parts of Switzer-land. The tour is not to be hurried, and it will bepossible to combine instruction with recreation, andparticularly with that change of scene, right in themiddle of our sunless winter, which has been shownby so many ex-Alpine patients to be a factor inmaintaining their health. The party will leaveLondon at 2 P.M. on Sunday, Dec. 18th, and thefollowing day will reach Zurich, where they will visitthe hospitals and university. Wednesday will bespent at Arosa, the highest health resort in Switzerland ;Thursday and Friday will be devoted to Davos, wherethe party will be entertained by the Kurverein, andthe next four days, including Christmas, will be passed

1 Acta Pædiatrica, vol. vi., Supplementum, Feb. 7th, 1927.Contribution à l’étude des splénomégalies do l’enfance.

at St. Moritz and Maloja, so as to see something of thewinter sports. On Tuesday, Dec. 27th, the party willdrive into Italy to reach the Hhone Valley and willspend the night in Milan, after which they are toreturn to Switzerland to visit Montana, as the guestsof Sir Henry Lunn, and to see Dr. Itullier’s famousclinic at Leysin, where the tour will end on Dec. 30th.The participants will then be at liberty to return toEngland or remain in Switzerland as they please.Further particulars may be had from the lion.secretaries of the Institute at 37, .1 lussell -square,London, AV.(’. 1. _____

HAIR DYES.

THOUSANDS of years of experiment have failed toprovide a hair dye which is definitely harmless andat the same time satisfies the popular demand. Dr.0. L. Levin, in the Medical Journal and Record ofAugust 17th, divides the dyes in common use intothree classes-the purely vegetable, of which hennais alone convenient, the metallic, and the syntheticorganic. Henna is harmless, but will only dye thehair red, the so-called brown or black henna dyescontaining metallic compounds. Metallic dyes, whichform the bulk of the preparations usually exposed forsale, are most of them composed of a salt of silver,copper, mercury, tin, lead, or bismuth, mixed with adeveloper, which is usually pyrogallic acid. Silverdyes may contain sodium thiosulphate instead. Thedepth of the tint obtained depends on the amount ofcopper deposited as a sulphide on the surface of thehair. The pyrogallic acid corrodes and ultimatelydestroys the hair, and the copper is absorbed by thebody in quantities that may be physiologically toxic.The danger of all metallic dyes lies in the necessity fortheir repeated application, which affords an oppor-tunity for the metal to accumulate in the tissues andproduce an obstinate illness. Lead is particularlypoisonous and there is little doubt that its use shouldbe absolutely prohibited. Probably the only metallicsalt that is quite harmless is permanganate of potash,which is too slow and uncertain in its action to be ofmuch value. The synthetic dyes are prepared ona base of paraphenylenediamine, a derivative ofaniline, and are so noxious that nearly every Europeancountry forbids their use. They penetrate the hair-shaft and so give a much more lasting result than themetallic compounds. But for their virulent effectthey would solve the problem very well. Thesymptoms that may be caused by poisonous hair dyesare local or constitutional, or both. The local reactionmay be an acute dermatitis extending over the head,neck, face, and ears, and proceeding to oedema andvesiculation. This sometimes clears up. untreated ina few days, but often the violent itching makes thepatient scratch, and eczema and other secondaryailments follow. The itching may persist for monthsunder treatment after the eruption has disappearedCutaneous tests may discover whether a given personis likely to react to a dye in this way, but probablyno one is quite immune from constitutional metalpoisoning, and users have been known to react locallyafter tolerating many previous applications. Shortof prohibiting the sale of all dyes containing noxioussubstances, as has recently been done in New York,it is useful to insist on their correct description at sale.

SYNDROMES IN PHARMACOLOGY.

WHY adrenalin acts specifically on the sympatheticterminations, or why apomorphine attacks thevomiting centre, are examples of a question whichpharmacology has so far failed to answer. Any methodwhich suggests an approach to this fundamentalproblem of the specific action of drugs is welcome.Certain simple reactions can be explained ; theastringency of tannic acid, for instance, is generallyadmitted to be due to the coagulation of proteins,and saponins bring about haemolysis by dissolving thelipoid constituents of the cell envelope. Nevertheless,these phenomena are exceptional, and the bulk of