W. W. Payne

Liver Damage in Gastro-Enteritis

Jaundice in gastro-enteritis is described as a rare terminal event (Sakula, 1943) and has been commonly regarded as a manifestation of septicaemia, as for instance in Buhls disease (Capon, 1934). Recent advances in our knowledge of liver disease, particularly in relation to malnutrition, cast considerable doubt on this explanation, and BonhamCarter (1947) has pointed out the significance of the various pathological changes which are found in the liver in fatal cases of gastro-enteritis. There is some reason to believe that the post-mortem appearances of cell damage, fatty infiltration, and early fibrosis which have been described, alone or in combination, depend to some degree on the severity and duration of the disease. This cannot be confirmed until the exact sequence of events is defined by a systematic study of liver biopsy material. The purpose of this paper is to put forward further views regarding the cause of these liver complications, based chiefly on clinical observation, and to describe a method of treatment which has proved successful in a condition which up to the present has almost inevitably proved fatal. In five of the six cases about to be presented, clinical evidence of severe liver damage was found. In the sixth some of the features which can be recognized as a syndrome were lacking, but as it compared so closely in other respects to the group as a whole it has been included in the series. Potassium deficiency was the other striking change and was present in all six patients. The serious effect of loss of this salt from the system in gastroenteritis and the reduction of mortality when it is made good have been described by Darrow (1946). We have confirmed this in many instances without obvious liver failure, but its association in the present series is noteworthy and calls for consideration of a possible relationship.

DIABETES MELLITUS IN CHILDHOOD.

events are playing a prominent part in causing it. Menopausal conditions and certain cases of sexual excitability also appear to be particularly helped by bromide, as are cases in which there is much irritability. Bromide acts by replacing the chlorides in the body, the rate of substitution depending upon the quantity of bromide given, the fluid and chloride intake, and the renal efficiency of the individual. As the salt intake varies from individual to individual, so the amount of bromide remaining in the body after a standard dose also varies. If 50 grains of bromide are given to one person who is on a low salt diet and has a small fluid intake the blood bromide at the end of twenty-four hours will be appreciably higher than when the same amount of bromide is given to a patient who is on a normal diet. Therefore prescribing bromides without knowing the chloride-fluid intake is tantamount to prescribing an indefinite quantity of bromide. This, in part, explains why certain patients, receiving 10 grains of bromide three times a day, develop toxic symptoms in four to five weeks, while others can take the same dose for twelve months and benefit from it. It is difficult, therefore, to lay down rules as to dosage for any given individual. This must be arrived at by observing the effect of varying amounts of the drug. The treatment of bromide intoxication when established or suspected is a simple procedure. The bromide is immediately stopped, large quantities of fluid, preferably normal saline, are given by the mouth, and sodium chloride, 20 to 40 grains, is administered four-hourly. Figures given in a previous paper by one of US7 showed that when no salt was given relatively high amounts of bromide were still present in the blood of patients one to three months after the medicine had been discontinued.

A Dietetic Approach to the Coeliac Affection

The coeLiac affection occurs among children of all financial grades of the population, making its appearance some time between the ninth month of life and the end of the second year. Its incidence has been on the increase since before 1939, partly, no doubt, due to a more frequent recognition of its features. The war cannot be entirely blamed as, both during hostilities and since, food rationing has provided a better balanced diet in many homes, and more intense propaganda on food values has been provided by child welfare clinics. The traditional method of treatment, concentrating on reduced fat intake, was unsatisfactory, leading by a lengthy and laborious progress to an often imperfect recovery. Some improvement in results followed the high vitamin B therapy of May, McCreary, and Blackfan (1942), but there was still a large residuum of complete or partial failures and of recurres. It was decided, therefore, during the war, to investigate the treatment advocated by Bircher-Benner (1935) who, in his Zurich clinic, had obtained good results with a fruit and vegetable diet. A case of coeliac disease, first diagnosed at 3 years of age, had been placed on this diet at the age of 6 years, and gained 14 lb. in eight months with an increase in height of three inches. Simila, though modified, treatment had been introduced by Feer (1929) at the Kinderklinik, Zurich, and later continued by his successor, Fanconi. Fanconi (1930) referred to favourable results in 50 typical cases of coeliac disease treated with the fruit and vegetable diet. The present report describes the treatment of 25 cases of coeliac disease. The first 19 of these were given the fruit .and vegetable diet advocated by Bircher-Benner (Bircher-Benner diet).* At first this diet was followed exactly, but with the passage of time disadvantages became evident and eventually only nine cases continued on the strict regime. The diet of four cases had to be modified by the addition of appreciable amounts of protein, and two cases relapsed and died. Gradually a new diet was evolved, being a modification of that used by

Hæmostatic therapy in hæmophilia

SummaryThe bleeding time is of no value in indicating the liability to hæmorrhage in hæmophilia.No method except the injection of intravenous whole blood or plasma produced more than a transient unimportant improvement in the coagulation time. In the majority of cases a period of-decreased coagulability occurred of longer duration and greater magnitude than the preceding stage (if any) of increased coagulability.The most effective agents, both for treatment and pre-operative prophylaxis, are citrated whole blood and citrated plasma given intravenously.We are indebted to Dr. R. Frew and Mr. O. L. Addison and Mr. Tyrrell Gray for permission to use their cases, and also to Miss E. M. Taylor for some of the coagulation times.