1117

absence, and distribution of H.C.G. and H.C.G.-like molefrom the diversity of reagent of and lack convincing chemical data on the probes of the materials nature being assayed. Perhaps the term material H.c.G.-like encompasses several different subwith stances immunological cross-reactivity. Future work in this area must include immunochemistry and attempts to ascertain, at a histological level, the normal .and neoplastic cell types responsible for production of H.C.G. and H.C.G.-like materials. At present the verdict for ubiquitous H.c.G. is "not proven". cules

seems to emanate

INTESTINAL FISTULAS French surgeons have been greatly interested in fistulas ever since Ambroise Pare treated the "inflamed, swollen wounds issuing from the guts" of his 16th century battle casualties. This Gallic influence is maintained in the opening paper of the Barber’s Company symposium on intestinal fistulas. Monod-Brocal analyses the dramatic fall in mortality (from 60% to 30%, or even to 10% in selected series), during the past decade in the treatment of small-bowel fistulas, of which 90% result from some form of surgical operation. He attributes this improvement to three major therapeutic advances-parenteral nutrition; low-flow enteric nutrition (usually with elemental diets); and irrigation with lactic acid. Few would disagree with the first two factors, but the Tremolieres technique2 of lactic-acid irrigation of the fistulous wound is probably less important than the local mechanical protective measures described by Irving3 in the second paper of the symposium. Sump drainage can now be replaced or supplemented in most patients by combinations of a modern stoma appliance, karaya gum or paste, and ’Stomahesive’ (a compressed wafer of gelatin, pectin, and methylcellulose which can be cut to shape around the fistulous opening). There is much scope for ingenuity in this work, and a nurse who supervises all fistulas can become a valued expert in any hospital. Early aggressive surgery has little place in enterocutaneous fistulas. For at least four weeks surgery should be restricted if possible to treatment of general peritonitis, drainage of abscesses, creation of a feeding enterostomy (usually a jejunostomy), and defunctioning of diseased bowel. During these weeks, the patient is maintained by intensive nutritional support.4 This may be parenteral (intravenous) or enteral. During the first few days of resuscitation and control of sepsis the intravenous route is usually necessary, but later, as the patient improves, it may be possible to change to enteral feeding by nasogastric intubation or surgically fashioned jejunostomy. Only the commercially produced (and very expensive) elemental diets are discussed, although they are probably no better in most cases than the cheaper substitutes which can be made up in any good hospital diet-kitchen.5 Despite all such valiant attempts to maintain nutrition, some 20-30% of the fistulas will not close spontaneously and so come to definitive operation which can "encompass the whole of gastro-enterological surgical practice." Whilst the outlook for intestinal fistula is 1. Monod-Broca, P. Br. J. Surg. 1977, 64, 685. 2. Trémolières, J., Bonfils, S., Gross, J. Arch. Mal. Appar. dig. 1961, 50, 636. 3. Irving, M. Br. J. Surg. 1977, 64, 690. 4. Holmes, J. T. ibid. p. 695. 5. Allison, S. P., Woolfson, A. M. J. Lancet, 1975, ii, 507.

today better than it was even ten years ago, one of surgery’s most disheartening sights is still the elderly, patient, with cancer or Crohn’s disease, who, a few days after emergency intestinal resection, produces that first dreaded spot of malodorous bile on his wound dressings CARDIOMYOPATHY AND CORONARY-ARTERY DISEASE

congestive cardiomyopathy conjures up the obscure disease of cardiac muscle whose of an picture unknown. cause is Patients with this disorder present with unexplained heart-failure, clinical and radiological evidence of cardiomegaly, diminished left-ventricularwall movement, and reduced left-ventricular ejection fractions.’ An identical clinical picture may, however, arise in some patients with coronary-artery diseasesometimes in the absence of a history of angina or myocardial infarction.2-4 The prognosis is poor and examination of the hearts of such patients shows focal areas of myocardial fibrosis interspersed with normal-looking myocardium.4 In life, cardiac radioisotope scanning with thallium-201 has been suggested as a way of separating the cardiomyopathy associated with coronary-artery disease from primary congestive cardiomyopathy. Dash and others6 have tried to quantify more precisely the relationship between chronic heart-failure and coronaryartery disease. 30 of 84 patients with coronary-artery disease were found to have a "cardiomyopathic syndrome due to coronary artery disease". This was-defined as heart-failure caused by multiple and widespread abnormalities of left-ventricular-wall motion due to coronary-artery disease, resulting in a reduction of left-ventricular ejection fraction to less than 50%. Excluded were patients with mechanical causes for their heart-failure such as disorders of the mitral-valve apparatus, damage to the interventricular septum, ventricular aneurysms, or poor movement of the left-ventricular wall localised to one segment. This syndrome was found to be specifically related to the extent of proximal coronary-artery disease and to the occurrence of previous multiple myocardial infarctions. The cardiomyopathy found in diabetics, although commoner than in non-diaTHE term

betics, seems indistinguishable.’ This pattern of obscure chronic heart-failure with the clinical picture of congestive cardiomyopathy fits into the end-stage of the natural history of coronary-artery disease. Before congestive cardiomyopathy is diagnosed, therefore, coronary-artery disease should be excluded. Although coronary-artery vein bypass grafting should be avoided in such patients, since it carries an increased surgical risk,4 one surgical teamS judges that cardiac transplantation has a place in this group. 1. 2. 3. 4.

Goodwin, J. F., Oakley, C. M. Br. Heart J. 1972, 34, 545. Raftery, E. B., Banks, D. C., Oram, S. Lancet, 1969, ii, 1147. Burch, G. E., Tsui, C. Y., Harb, J. M. Am. Heart J. 1972, 83, 340. Yatteau, R. F., Peter, R. H., Behar, V. S., Bartel, A. G., Rosati, R. A., Kong, Y. Am. J. Cardiol. 1974, 34, 520. 5. Bulkley, B. H., Hutchins, G. M., Bailey, I., Strauss, H. W., Pitt, B. Circulation, 1977, 55, 753. 6. Dash, H., Johnson, R. A., Dinsmore, R. E., Harthorne, J. W. Br. Heart J. 1977, 39, 733. 7. Dash, H., Johnson, R. A., Dinsmore, R. E., Harthorne, J. W. ibid. p. 740. 8. Rider, A. K., Copeland, J. G., Hunt, S. A., Mason, J., Specter, M. J., Winkle, R. A., Bieber, C. P., Billingham, M. E., Dong, E., Griepp, R. B., Schroeder, J. S., Stinson, E. B., Harrison, D. C., Shumway, N. E. Circulation, 1975, 52, 531.

Cardiomyopathy and coronary-artery disease.

1117 absence, and distribution of H.C.G. and H.C.G.-like molefrom the diversity of reagent of and lack convincing chemical data on the probes of the...
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