M. O. Rake

EARLY AND INTENSIVE THERAPY OF INTRAVASCULAR COAGULATION IN ACUTE LIVER FAILURE

Four consecutive patients, three with fulminant hepatic failure and one with a severe relapse of serum hepatitis, who showed evidence of intravascular coagulation, were treated intensively with heparin and fresh frozen plasma. Rapid correction of the coagulation disturbance was achieved, and all four patients recovered completely. The necessity for starting such treatment early in the course of the disease and before the onset of major gastrointestinal bleeding is stressed, and it is suggested that intravascular coagulation may act as an intermediary in the pathogenesis of the hepatic necrosis.

Ligation of the hepatic artery in the treatment of heart failure due to hepatic haemangiomatosis

An infant presenting with high-output cardiac failure and a single large diffuse haemangioma of the liver is described. Corticosteroid therapy failed to produce any improvement, but hepatic artery ligation was followed by dramatic disappearance of the signs of cardiac failure and a decrease in the size of the liver without any evidence of lasting liver damage.

Liver Transplantation in Man—IV, Haemorrhage and Thrombosis

Blood coagulation and fibrinolytic factors have been measured in 13 patients treated by liver transplantation. During operation intravascular coagulation and fibrinolysis were increased, but seldom to a degree which would cause abnormal bleeding. Measurement of the catabolism of radioactive fibrinogen showed that increased intravascular coagulation continued for long periods after the operation. Despite secondarily increased fibrinolysis, there was a high incidence of thrombosis. Treatment with anticoagulants or with fibrinolysis inhibitors may be valuable in these patients.

Liver Transplantation in Man—III, Studies of Liver Function, Histology, and Immunosuppressive Therapy

The experience gained from 13 hepatic transplant operations is described, with particular reference to the findings in nine patients who survived the immediate operative period. A major problem was found to be infection. Fulminant pneumonia caused death in two adults, at a time when liver function was virtually normal. Infection related to bile fistula and sepsis may be overcome by an improved method of biliary drainage by cholecyst-dochostomy, which was carried out in the last two patients. Jaundice in the second week due to rejection was observed in several patients. The striking histological change was centrilobular cholestasis. The jaundice, which was not prevented by administration of antilymphocyte globulin, was rapidly controlled by temporarily increasing die dose of prednisone. One patient who survived for four and a half months and who had a poor tissue match subsequently developed chronic rejection with progressive cholestatic jaundice. Five of the patients were able to go home and at time of publication two are alive and well 14 and 20 weeks after treatment.

Universities without walls: evolving paradigms in medical education

Medical education is entering a phase of renewed change driven by developments in information availability and technology. Over the past half century medical education has remained largely isolated from the changes that have swept through most other businesses: enterprise-wide computerisation, client centred thinking, and a service philosophy. The clients of the medical education process, who, worldwide, generally pay for themselves (though in some countries they are state funded) are guaranteed little for their money, often not even a modern, efficient, or entirely relevant educational programme. Many leave medical school financially poorer and often little enriched cognitively: they are generally weighed down under a vast burden of obsolescent information, the important elements of which could be found by an intelligent member of the lay public faster and in an updated form directly from the world wide web. They are also changed culturally, not necessarily for the better. Their time spent studying in the academic ivory towers, from which most graduate, separates them from their community roots and also reinforces the divide between primary and secondary care and does little to emphasise the essential humanity and caring intrinsic to this vocation.1 #### Summary points A wealth of information about biomedicine and health care is available in electronic formats, and this can be synthesised into courseware for medical education and distributed electronically For many, the study of small or larger parts of medicine could be a recreational pursuit; for others, it might be a vital venture in self understanding in order for them to manage health risks and play a greater part in decision making about their health For much of the time, course developers, tutors, and students can readily be separated in time and space and effectively linked by electronic communications: there is no need for co-location of all resources at a single site …

Experimental hepatic necrosis: Studies on coagulation abnormalities, plasma clearance, and organ distribution of 125I-labelled fibrinogen

Studies in the rat with hepatic necrosis induced by carbon tetrachloride showed that the abnormalities in one-stage coagulation tests and the increased catabolism of fibrinogen were similar to those found in man with acute viral or drug-induced hepatic necrosis. Determination of the distribution of the radioactive label shows that excessive deposition was maximal in the liver but also occurred in the spleen. The appearance is delayed by heparin but accelerated by tranexamic acid.

Controlled Trial of Phetharbital, a Non-hypnotic Barbiturate, in Unconjugated Hyperbilirubinaemia

Eleven patients with mild unconjugated hyperbilirubinaemia (Gilberts syndrome) took part in a double-blind cross-over trial of phenobarbitone and phetharbital, a non-hypnotic barbiturate. Significant reductions in plasma bilirubin were observed with both drugs, but six patients complained of sleepiness on phenobarbitone, and phetharbital was preferred by most patients. Phetharbital was also effective in the rare severe unconjugated hyperbilirubinaemia of the Crigler-Najjar syndrome (Type 2). Symptoms attributed to Gilberts syndrome, including nausea and abdominal pain, were less consistently relieved.

Malignant Carcinoid Tumour with Gangrene of the Small Intestine

Four patients with a malignant carcinoid tumour of the small bowel (three had the carcinoid syndrome) developed gangrene of the small intestine. Attention is drawn to this seldom recognized complication, as early surgery may be life saving.

Syphilis as Acute Neurological Illness

and one deep to the tendon. The tendon guides the knife to the upper edge of the transverse carpal ligament. The knife is then pushed into the palm and can be felt cutting the fibrous ligament. In following the plane of the ligament the knife is held at about 20° to the skin surface. The whole operation, including injection of local anaesthetic and the insertion of two stitches, can be completed without haste in under three minutes. Although most of the operations were done using a Smillies knife, this instrument proved a little large and clumsy for this purpose and so a special knife based on the same principle was recently designed (Fig. 1). The knife is 7J in. long (19.6 cm.) and i in. (6.4 mm.) wide at its cutting edge. The depth can be gauged by inch markings on the upper edge of the neck, and pushing the knife in 1l in. (3.77 cm.) is enough to cut through all the transverse ligament. The instrument is manufactured by Thackrays Ltd., Leeds. Of the 32 cases done by this simple ligament-slitting technique under local anaesthesia, all were immediately relieved of their pain. A few developed ecchymosis in the palm but no palmar haematoma of any significance was encountered. Two cases developed a recurrence of symptoms within a few weeks. One of them had an open operation done and the transverse carpal ligament appeared to have re-formed and showed marked thickening. It was excised. In the second case a cure was gradually effected after several injections of hydrocortisone.I am, etc., JAMES PATRICK. Department of Orthopaedic Surgery, Glasgow Royal Infirmary.

Hepatic scintiscanning in fulminant hepatic failure

Abstract Measurements of liver area on antero-posterior 99Tcm sulphur colloid scans in fulminant hepatic failure (FHF) showed reduction in liver size in six of the 33 patients and enlargement in three. By contrast, liver area was normal or increased in all 20 patients with severe acute hepatitis without encephalopathy. The serum bilirubin and aspartate aminotransferase were not significantly different between the two groups but there was greater prolongation of the prothrombin time in the FHF patients. All six patients with reduction of liver area on the initial scan died but neither the finding of a normal or enlarged liver area on admission nor serial liver scans were helpful in assessing the prognosis of an individual patient. Peak activity over the liver was sometimes higher than normal, possibly due to shrinkage of the liver with approximation of the Kupffer cells.