1377ANNOTATIONS

This is compatible with previous investigations, thoughthe corresponding figures for associated heart-diseasehave varied from 13 % to 80 %. If only fatal pulmonaryemboli were considered, then heart-disease was presentin 73% of BYRNE’s cases. About a quarter of theemboli in this series followed an operation ; and an

operation for a malignant lesion seemed especiallyliable to be followed by infarction. The association ofcarcinoma with spontaneous superficial and deep phle-bitis and sometimes pulmonary embolism is, of course,well recognised, and was described by TROUSSEAUin his patients and himself almost a hundred yearsago. Carcinoma of the pancreas may be the one mostoften associated with Trousseau’s sign, although inBYRNE’s postoperative patients cancer of the colonwas the chief culprit. Other conditions associatedwith postoperative embolism are venous stasis due tobed rest, dehydration, shallow pulmonary ventilation,trauma to the venous intima, and changes in coagula-bility of the blood. Platelet stickiness, rise in fibrinogenlevel, and shortened coagulation time are among theblood defects recognised. 6% of BYRNE’s cases wereassociated with infection, 5% with pre-existing vari-cose veins, 5% with childbirth, and 5% with hemi-plegia. BYRNE has reviewed only those patients inwhom the pulmonary infarction was associated withclinical signs of venous thrombosis in the calf. Butit is common experience (for the physician as well asthe surgeon) that most lethal emboli strike withdramatic suddenness, bringing vicious chest pain andhaemoptysis before any diagnosis of limb thrombosishas been made.15 Death may sometimes be heralded

by premonitory emboli, but usually it is the first

episode that is (almost instantaneously) fatal.16The foremost problem is prevention, and there is

little progress to record. The popularity of earlypostoperative ambulation has waxed and waned.DE BAKEY concludes that those institutions whichhave faithfully pursued early postoperative ambula-tion have proved no decrease in the incidence of

pulmonary embolism ; indeed, in many there has beenan increase. But FARQUHARSON 17 holds that reallyearly ambulation does prevent thrombosis. There isa growing conviction that prophylactic division of thefemoral veins is unjustified, although the method isstill much used, especially in the United States, inelderly patients and those prone to thrombosis. Wecannot with certainty prevent emboli, and it is noeasier to detect the thrombosis before the clot frag-ments. Tests for this purpose have been designedfrom time to time, but none has been satisfactory.Even when it comes to the management of a patientin whom an embolism is suspected, there is no generalagreement. The Swedish workers, led by JoR,PES 18 andBAUER,19 have made a good case for anticoagulants.Femoral or more proximal venous ligation has equallyenthusiastic supporters, including BYRNE. Othersbelieve that, as it is the first embolism that kills, ifthe patient survives he has little to fear from laterones. There is statistical evidence for this view, butat present most people will be prepared to disregardit and use anticoagulants when there is a threat of

phlebitis, phlebothrombosis, or embolism.15. Marks, J., Truscott, B. M., Withycombe, J. F. R. Lancet, 1954,

ii, 787.16. Paaby, H. Acta chir. scand. 1955, 109, 319.17. Farquharson, E. L. Lancet, Sept. 10, 1955, p. 517.18. Jorpes, J. E. Heparin in the Treatment of Thrombosis.

London, 1940.19. Bauer, G. Lancet, 1946, i, 448.

Annotations

TUBERCULOSIS AND LIVER BIOPSY

HÆMATOGENOUS dissemination of tubercle bacilli is

regarded as a rare complication of localised tuberculosis,except in the early post-primary period and in the terminalstages of the disease. Certainly, attempts to cultivatethe organisms from the blood-stream at any stage of thedisease fail with very few exceptions. But the findingsof Haex and Van Beek,l who performed aspiration liverbiopsies on 189 proven cases of tuberculosis and 150controls, suggest that, despite the negative blood-cultures,dissemination via the blood-stream is a frequent, andperhaps almost invariable, accompaniment of thelocalised disease. Objective evidence of dissemination,revealed as submiliary tubercles in the biopsy specimen,was found in almost every form of tuberculosis, includingprimary infection, "

typho-bacillosis," pleurisy, peri-carditis, peritonitis, and lymphadenitis, as well as in casesinvolving the lungs, kidneys, adrenals, eyes, bones, andjoints. Positive results were also obtained in 14 out of 20cases of erythema nodosum and, still more surprisingly, ineach of 4 cases of erythema induratum (Bazin’s disease).Haex and Van Beek emphasise that the remarkably highproportion of positive results in their series was obtainedonly by meticulous search of every one of the hundredor so serial sections into which each biopsy specimenwas cut.In many patients the evolution of the disease wasfollowed by repeated biopsies. For this purpose the

hepatic lesions were classified according to their location,size, presence or absence of caseation or fibrinous exudate,the type of cellular exudate, and the presence and typeof giant-cells. Acid-fast bacilli could almost always bedemonstrated in lesions undergoing caseation, but rarelyin non-caseating tubercles. Only 4 out of 70 guineapiginoculations proved positive. The age of the lesion wasassessed by the proportions of epithelioid-cells, fibroblasts,fibrocytes, and scar tissue with or without hyalinisation.In many patients there was evidence of hæmatogenousdissemination continuing for several months despite whatis usually regarded as adequate treatment with strepto-mycin and p-aminosalicylic acid. A similar study of563 liver biopsies in tuberculous patients recently reportedby Oldershausen et al.2 only partly confirms the findingsof Haex and Van Beek. In this investigation miliarytubercles, or what the authors term "retothelial nodules,"were found in 193 specimens-an incidence of about 34%.In the 384 patients with " non-h2ematogenous

"

pulmon-ary tuberculosis the incidence was 26.5%.

This rather striking difference in the results of thetwo investigations may, at least in part, be accountedfor by differences in technique and the thoroughness withwhich the specimens were searched. The matter is

obviously of considerable importance not only in thediagnosis and treatment of tuberculosis but in the effectit may have on our views about pathogenesis.

OLD PEOPLE’S REAL NEEDS

UNTIL 1948 institutional care of those in need was

provided by the local authority, generally in public-assistance institutions. Most of these were built inthe middle of the 19th century to cope with vagrancyand destitution, which had greatly increased after theIndustrial Revolution. Grey and cheerless, with narrowdormitories approached by steep stone staircases, theyreflected the austerity of the Early Victorian approachto the problems of social inadequacy.1. Haex, A. J. C., Van Beek, C. Tuberculosis and Aspiration Liver

Biopsy : Its Clinical Significance in Diagnosis and Therapy.Haarlem: Erven F. Bohn. 1955. Pp. 106.

2. Oldershausen, H. F. V., Oldershausen, R. V., Tellerz, A. Klin.W schr. 1955, 33, 104.

1378 ANNOTATIONS

In time the need for this kind of accommodationwas largely limited to the aged and infirm and to a fewchronic sick in the younger groups. Wards as well asdormitories were required for these residents, and manylocal authorities used the powers conferred on them tobuild modern hospital units or to adapt the old institu-tions. Thus, when the National Health Service wasstarted in 1948, most institutions included hospitalaccommodation, varying widely in comfort and efficiency,as well as the " House," or residential section, wherepeople with social rather than medical needs were

admitted.

By the National Health Service Act of 1946 responsi-bility for those in need of hospital care was given to theregional hospital board, while the welfare work carriedon in the same institution was left under the local

authority. To cope with this administrative problem,a joint-user arrangement was brought into force, andthe authority owning and controlling the institution-generally the regional hospital board-continued to

provide accommodation for those who were the responsi-bility of the other authority. When the hospitalaccommodation of the old institutions was thus drawninto the main hospital service many of the defects dueto its historical development were put right. In manyareas wards were reconstructed and redecorated; treat-ment centres equipped with facilities for investigationand treatment were set up ; and a more enlightenedapproach to the disabilities of old age was introduced.Nevertheless much still remains to be done. The obviousneed for home-like living quarters has stimulated somelocal authorities to provide separate small hostels for oldpeople outside the institutions, but many are still accom-modated in the residential sections of the old institutions.

Though in some places attempts have been made toimprove this accommodation, in others conditions remainsubstantially the same as they have been for manyyears. Modernisation of the buildings is expensive,and if the institution is under the regional hospital boardimprovement of the residential part has to compete withother hospital needs.A report 1 on these institutions, made lately by a

working party of West Cornwall Hospital ManagementCommittee, remarks on the vivid contrasts between thelistless degenerating residents in the jointly used institu-tions and the bright vivacity shown by those in the

County Council’s Old People’s Homes. "Those in

jointly-used institutions are for the most part content tosit thoughtless, despondent, and inactive all day long,the only interruption to their monotony being mealtimes.In the Old People’s Homes there is an active interest inlife, the residents get out and take part in the life ofthe community, join local libraries and are obviously verymuch alive." So sharp was the contrast between thesetwo groups of old people that the working party atfirst thought that it must be due to selection of thosesent to the hostels. But during their survey at oneinstitution, where the old people lived and had theirmeals with low-grade imbeciles, the working party foundone old man " who was still alert, intelligent and self-respecting " and discovered that he was the last personto be admitted. They began to wonder whether in suchan atmosphere it would not take " a man of unusualstamina to hold on to a decent standard of life ’’ ; and

by the end of their survey, which included visits toinstitutions where the accommodation was " worse thanis usual in common lodging-houses," they had decidedthat it is not " surprising that there is rapid deteriorationafter admission to such places." This survey shows that,in one part of the country at any rate, the situation isnot nearly so satisfactory as Miss Hornsby-Smith makes’out in a parliamentary answer reported on a later page.

1. Western Morning News, June 29, 1955.

Clearly the accommodation in institutions should belargely replaced by further small residential homes;but in planning these it should be borne in mind thata main object of our welfare services for elderly peopleshould be to enable them to remain comfortably athome in their familiar surroundings and near theirfriends. The hostel, however well run, cannot be a

complete substitute for home, and it should be reservedmainly for infirm old people who require more care andattention than can be given them at home. Yet manyof the smaller hostels opened in recent years, excellentthough they are in many ways, only accept residentswho can, for instance, go upstairs unaided and attendto their personal needs. In planning future hostelsthe needs of the frail or infirm old person should be met

by providing more ground-floor bedrooms and dormi-tories or by installing lifts. More staff will also be neededto help them during the night, and to nurse them inshort illnesses. Hostels for frail old people may be moredifficult and expensive to run ; but, as so often, it isthe difficult and expensive that is needed and that mayprove the easiest and the cheapest in the long run.

T.S.H. AND EXOPHTHALMOS

THE idea that the thyroid-stimulating hormone (T.s.H.)produced by the anterior pituitary might be thecause both of thyrotoxicosis and of the exophthalmoswhich often accompanies it has been under discussionfor the past twenty years or so. It still remains no morethan a suggestion which, after much hard work in manyquarters, has not yet been either, dismissed or finallyproved. The latest work on the subject was describedat a recent meeting of the section of endocrinology -ofthe Royal Society of Medicine by Prof. A. Querido, ofLeiden, and Dr. I. Gilliland. Each had developed hisown method of estimating T.s.H. in the blood. ProfessorQuerido used the rate of uptake of p31 by the mousethyroid as an index of T.s.H. activity, while Dr. Gillilandused the rate of decay of thyroid radioactivity in chickswhich had already received a loading dose of 1131. Thetwo methods seemed to have about the same degree ofsensitivity and reliabilitv, and the results obtained wereremarkably similar. The amount of T.s.H. in the bloodof normal persons is only just detectable in most cases,and in some none may be found. Patients with myx-oedema from any cause (except pituitary failure) nearlyalways have an increased T.S.H. level -in the blood.Dr. Gilliland bad, however, seen a few cases of extrememyxeedema without detectable circulating T.s.H. He

explained these by suggesting that in prolonged severehypothyroidism the pituitary is itself affected and canno longer make T.S.H. This view was strongly supportedby the finding, in one of Dr. Gilliland’s cases, that T.s.H.was originally absent but after brief and partial treat-ment of the myxcedema it appeared in the blood in quitelarge quantities.

In patients with thyrotoxicosis, but without exoph-thalmos or other eye signs, the level of circulating T.S.H.is no greater than normal. It may also be normal insome cases with well-developed eye signs, but in othersthere may be extremely high values. Both speakers atthe Royal Society of Medicine agreed that there was ageneral tendency for exophthalmos to be associated withhigh levels of circulating T.,9.ii., but when studied indetail the correlation often broke down. In particular,Professor Querido was much impressed by a single case,in which the exophthalmic ophthalmoplegia syndromeprogressed rapidly, in spite of a low level of T.s.H. illthe blood.

The mere fact that patients with myxcedema havemuch T.S.H. in their blood, but no exophthalmos, is

enough to disprove the simplest a,nswer to the problem.It seems clear that a complex situation exists which can