organisms, which respond to treatment with antibiotics. Rheumatoid-arthritis patients without leucopenia are also prone to chest infections and septic arthritis, but not to the same degree as those with Felty’s syndrome. This suggests that leucopenia is an important factor, although the frequency of infections does not correlate with the neutrophil-count and there are obviously other reasons why infection might arise in a patient with severe joint disease. Since splenectomy corrects the leucopenia it should reduce the tendency to infection. Long follow-up suggests that this is true for some but by no means for all patients with severe infections; some mon

continue to have infections of the same sort and with the same frequency as before operation.2-1 A few patients die within weeks or months of operation with an overwhelming septicaemia. It seems that loss of the spleen takes the place of leucopenia as the critical factor reducing resistance to infection. Thus, the decision to operate is finely balanced. Some patients with severe recurring infections benefit, but minor infections are not an indication-and splenectomy should never be done merely to correct a low white-cell count.

DIAGNOSTIC PERITONEAL LAVAGE IN BLUNT TRAUMA CLINICAL and radiological assessment of the patient with suspected abdominal injury is a hallowed ritual but often a misleading one. The mortality from such injuries is disturbingly high--especially when they have escaped notice because of more obvious damage to head, chest, or limbs. After a high-velocity road accident even needle paracentesis or four-quadrant tapping of the suspicious abdomen is insufficient co exclude serious injury, and in 1965 Root and others’"advocated peritoneal lavage via a cannula introduced under direct vision through a small infra-umbilical incision. Now this is routine practice in major trauma centres in the U.S.A 11 The peritoneal cavity is washed out with 500-1000 ml of clear cystalloid solution and the returning fluid is examined for blood-staining. (More elaborate analysis of the fluid for red and white cell counts and amylase content yields little extra information.) Only lately has abdominal lavage been used to investigate the injured child. A




center" in Minnesota


its results on 230 children, under the age of 10, over 13 years.12 The lavage was done with the child under sedation (not specified), 15 ml per kg of Ringer’s lactate being rapidly infused. Intra-abdominal injury was correctly diagnosed in 99% of the children. There was one false-positive, blood having leaked into the peritoneal cavity from the lavage incision, and one false-negative, in a child with transection of the jejunum; the only important complication was herniation of a loop of small bowel through the incision. Almost 90% of laparotomies were carried out within 3 hours, and yet even in this centre of excellence the mortality was over 19%. Clearly the injuries being treated were very severe. For the general run of patients this frightening investigation is probably dispensible, provided that the patient is D., Hauser, C. W., McKinley, C. R., Lafave, J. W., Mendiola, R. P. Surgery, 1965, 57, 633. 11. Gill, W., Champion, H. R., Long, W. B., Jamaris, J., Cowley, R. A. Br. J. Surg. 1975, 62, 121. 12. Drew, R., Perry, J. F., Jr., Fischer, R. P. Surgery Gynec. Obstet. 1977, 145, 10. Root, H.


observed closely and operated on promptly when signs of abdominal trauma arise. Even then, probably too many laparotomies are done "just to make sure". But in hospitals which have to cope with many high-speed traffic accidents the aggressive American approach to diagnosis may well have a place--even in children.

PSYCHOTHERAPY FOR MULTIPLE SCLEROSIS? PSYCHOTHERAPY is a subject which raises strong emotions. And when the issue is the value of psychotherapy in a physical disease, feelings run even higher. Psychiatrists regard psychotherapy as a standard part of clinical practice in which the active ingredients are words and manipulation of the patient’s environment. Other physicians find the practice hard to accept. Where is the evidence, they ask, that psychotherapy is beneficial in psychiatric disorders? Yet in "psychosomatic" disorders such as peptic ulcer and asthma there are several reports that the technique is valuable, and lately psychotherapy has been advocated as a treatment for multiple sclerosis. Psychiatric concomitants of this disorder have been recognised for years. Some commentators have suggested that the personality of sufferers was in some way abnormal before the illness arose,2 and that emotional problems could precipitate relapses. The abnormal-personality suggestion has not stood the test of time or controlled investigation,3 but precipitation of recurrences by stress is a possibility which is still taken seriously; we know that life events antedate various ill-

including neurological disorders.4,5 Paulley6 suggests that psychotherapy not only helps in management of multiple sclerosis but also prevents relapse. Observations on more than 300 patients over 27 years led him to the view that "psychotherapy, especially couple-therapy, appears to offer greater promise than other forms of treatment".’ Unfortunately, the evidence for this is mainly retrospective. M.S. is well known for its spontaneous remissions, and factors implicated in relapse cannot be properly assessed by hindsight. Nevertheless, to date no treatment is outstandingly successful with this disorder, and the possibility that psychotherapy may have some specific role to play in management deserves closer investigation and trial. The fact that current evidence favours some abnormal immune mechanism in the disorder in no way devalues this notion: since the immunological response may change in bereavement and in various other kinds of stress,8 similar mechanisms may well be involved in the pathophysiology of multiple sclerosis. Medical writers of the 19th century continually made reference to the contribution of emotional factors to illness but such insights seem to have been lost in this scientific era. To deny that such links exist is to deny everyday experience. To measure the factors involved is difficult but within the bounds of science. nesses,

Kellner, R. Archs gen. Psychiat. 1975, 32, 1021. Grinker, R. G., Ham, G. C., Robbins, F. P. A Res. Publ. nerv. ment. Dis. 1950, 28, 456. 3. Pratt, R. T. C. J. Neurol. Neurosurg. Psychiat. 1951, 14, 326. 4. Rahe, R. H. in Consultation Liaison Psychiatry (edited by R. O. Pasnan). New York, 1975. 5. Penrose, P. J. J. psychosom. Res. 1972, 16, 329. 6. Paulley, J. W. Psychother. Psychosom. 1976/77, 27, 26. 7. Paulley, J. W. Practitioner, 1977, 218, 100. 8. Bartrop, R. W., Lazarva, L., Luckhurit, E., Kiloh, L. G., Penny, R. Lancet, 1977, i, 834. 1. 2.

Diagnostic peritoneal lavage in blunt trauma.

541 organisms, which respond to treatment with antibiotics. Rheumatoid-arthritis patients without leucopenia are also prone to chest infections and s...
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