274 some cogent thoughts from The Lancet. Cerdoes not have unanimous support for document the tainly every detail. But I think the final suggestions are close to the general feeling of that international and interdisciplinary workshop as they could possibly be.
pants,
including
accurate.
Ciba Foundation, London W1N 4BN
MAEVE O’CONNOR
SiR,—The discussion about the style of citations and refer-
distinguishes itself by two arguments which might perhaps be classed under the concept of extended chauvinism. One is the oblique reference to the Transylvanian journal of something or other. Very funny-especially for a reader who happens to live in, perhaps not Transylvania (Ruritania would not have been quite so tactless), but in another small country. It is not necessary to drive home that you are very big and some of us are small. Quality and quantity are not always correlated, and history suggests that medical scientists might have been better informed if they had taken a look at journals from the very country that comprises Transylvania. The second is medical chauvinism. True, some medical journals have a very great circulation. But even so, medical journals are not alone in this world, and anybody wanting to play the numbers game will have the duty to demonstrate that his favourite style is used by the majority of journals in the majority of copies. Since this is impossible, why cannot we look at matters rationally instead of playing this I’m-bigger-than-you game? The rational approach is the one that-under given circum-
ences
stances-best serves authors, editors, and readers. This is the type of discussion we have tried to conduct, both in ELSE (European Life Science Editors) and in the Ciba conferences. There are good arguments on both sides, and, for the time being, we have decided to agree to disagree. The model proposed by the Ciba Foundation workshop is an attempt to bring in as much agreement as possible in the technical execution of the manuscript. It should be considered in that light. If anybody has better ideas, I am sure both ELSE and the Ciba Foundation would be very glad to learn about them, but the argument that "things must be done like that because they have always been done like that, and besides I like it like that"-well it is not an interesting argument. University N-5014
Botanical Museum,
KNUT FÆGRI
Bergen, Norway
**For those like Professor Fsegh who had better
were
puzzled by
that it
explain Transylvanian sally, sion not to obscurity but to vampires.-ED.L. we
was an
our
allu-
ENDOSCOPIC TREATMENT OF BILIARY-TRACT DISEASE
SIR,-Dr Cotton’s remarks (Jan. 20)1 in response to our letter2 require
comment since he implies that references we cited inaccurate and inappropriate. We stated that in recent surgical experience the incidence of residual stones after exploration of the common bileduct was 1-4%, compared with the 10-11% after endoscopic sphincterotomy.I,3 In support of this we cited the work of Glen and McSherry.4 Certainly, as Cotton points out, these workers had a failure after surgery of 4-48% (table vn, p. 32) but these data were from their original series dating back to 1932. We chose rather to use results from their much more recent study (table vi, p. 31) in which the overall frequency of residual calculi was less than 1% and that after duct exploration was 3-2%. We judged that the recent results gave a much fairer comparison with a modern treat-
were
1. 2.
such as endoscopic sphincterotomy. Other recent studies5 confirm our statement and the results of Glen and McSherry. Cotton also implies that we gave Kune6as a reference source for the overlooked stones, but this was not so: the quotation in our letter referred to surgical mortality and was completely
ment
Cotton, P. B. Lancet, 1979, i, 150. Blumgart, L. H., Wood., C. B. ibid. 1978, ii, 1249. 3. Safrany, L. ibid. p. 983. 4. Glen, F., McSherry, C. K m Current Problems in Surgery (edited by M. M. Ravitch and others). Chicago, 1975. 5. Lawson, R. A. M., Gunn, A. A. Jl R. Coll Surg. Edinb. 1970, 15, 222.
Cotton- cites our statement that the mortality for endoscopic sphincterotomy "is comparable with or, as Safrany3 argues, better than surgical mortality". In relation to mortality we cited Kune6 who had a mortality-rate of less than 2% and our
results in which the rate was 1.6%. Cotton argues this is relevant since comparisons should be made with the results of second or third surgical exploration. We agree, but should explain that previous surgery had been performed in 52% of our patients undergoing biliary-enteric bypass for stones. Judicious use of choledochoduodenostomy gives excellent results with a low incidence of complications in patients with dilated ducts and multiple calculi in whom the residual-stone rate (were it primary or secondary exploration) tends to be high.’ Certainly we did not intend to imply that endoscopic sphincterotomy was being used too frequently for gallstone removal. Perhaps we should re-emphasise the major point of our letter which was that the technique appears to be used frequently for primary papillary stenosis. A mortality-rate of 1-4% does not seem justifiable for the treatment of a condition which defies precise diagnostic description. When commenting on papillary stenosis it seems reasonable to try and prevent the waves of endoscopic enthusiasm washing up on the same shore as the receding tide of surgical endeavour in the same ill-defined area.
own
not
Department of Surgery, University of Glasgow, Glasgow G4 0SF
L. H. BLUMGART C. B. WOOD
A.F.P. AND CONGENITAL NEPHROSIS FINNISH TYPE
SIR,-Dr Spritz and colleagues’ report a case of congenital nephrosis Finnish type (C.N.F.) in which normal ot-fetoprotein (A.F.P.) was found in the amniotic fluid in the second trimester of pregnancy. Congenital and infantile nephrosis consists of heterogeneous group of renal diseases. We have used the name C.N.F. to separate a genetically, clinically, and pathologically uniform type of congenital nephrosis from similar disorders. Since there is no single pathognomonic change or finding in C.N.F. we have emphasised a combination of typical findings for the diagnosis of this disease. The main criteria include low birthweight, large placenta, proteinuria and oedema in the first weeks of life (usually at birth), failure to thrive, and typical histological findings.23 Spritz et al. based their diagnosis on the renal histology alone, although they mention the normal placenta as an atypical feature. The normal birthweight at term and the appearance of nephrotic findings at 5 months are further indicators that practically exclude C.N.F. in their case, despite the microcystic dilatations of proximal tubules in the kidney-biopsy specimen. The most likely explanation for the increased amniotic-fluid A.F.P. in C.N.F. is heavy fetal proteinuria.4 It is not to be expected in cases where the proteinuria first appears several months after birth. We agree with Spritz et al. that congenital nephrosis is a heterogeneous group of diseases and that this has to be taken into account when A.F.P. determination is planned for antenatal diagnosis. But we also suggest that the diagnosis of c.N.F. should not be made on insufficient criteria, because so far the 6. Kune, G. A. Current Practice of Biliary Surgery. Boston, 1972. 7. Madden, J. L. Surg. Clins N. Am. 1973, 15, 1095. 1. Spritz, R. A., Soiffer, S. J., Siegal, N. J., Mahoney, M. J. Lancet, 1978, ii, 1251. 2. Hallman, N., Rapola, J. in Pediatric Kidney Disease (edited by C. M. Edelmann, Jr); p. 711. Boston, 1978. 3. Huttunen, N-P. Archs Dis. Childh. 1976, 51, 344. 4. Aula, P., Rapola, J., Karjalainen, O., Lindgren, J., Hartikainen, A. L. Seppälä, M. Am. J. Dis. Child. 1978, 132, 984.
pants,
including
accurate.
Ciba Foundation, London W1N 4BN
MAEVE O’CONNOR
SiR,—The discussion about the style of citations and refer-
distinguishes itself by two arguments which might perhaps be classed under the concept of extended chauvinism. One is the oblique reference to the Transylvanian journal of something or other. Very funny-especially for a reader who happens to live in, perhaps not Transylvania (Ruritania would not have been quite so tactless), but in another small country. It is not necessary to drive home that you are very big and some of us are small. Quality and quantity are not always correlated, and history suggests that medical scientists might have been better informed if they had taken a look at journals from the very country that comprises Transylvania. The second is medical chauvinism. True, some medical journals have a very great circulation. But even so, medical journals are not alone in this world, and anybody wanting to play the numbers game will have the duty to demonstrate that his favourite style is used by the majority of journals in the majority of copies. Since this is impossible, why cannot we look at matters rationally instead of playing this I’m-bigger-than-you game? The rational approach is the one that-under given circum-
ences
stances-best serves authors, editors, and readers. This is the type of discussion we have tried to conduct, both in ELSE (European Life Science Editors) and in the Ciba conferences. There are good arguments on both sides, and, for the time being, we have decided to agree to disagree. The model proposed by the Ciba Foundation workshop is an attempt to bring in as much agreement as possible in the technical execution of the manuscript. It should be considered in that light. If anybody has better ideas, I am sure both ELSE and the Ciba Foundation would be very glad to learn about them, but the argument that "things must be done like that because they have always been done like that, and besides I like it like that"-well it is not an interesting argument. University N-5014
Botanical Museum,
KNUT FÆGRI
Bergen, Norway
**For those like Professor Fsegh who had better
were
puzzled by
that it
explain Transylvanian sally, sion not to obscurity but to vampires.-ED.L. we
was an
our
allu-
ENDOSCOPIC TREATMENT OF BILIARY-TRACT DISEASE
SIR,-Dr Cotton’s remarks (Jan. 20)1 in response to our letter2 require
comment since he implies that references we cited inaccurate and inappropriate. We stated that in recent surgical experience the incidence of residual stones after exploration of the common bileduct was 1-4%, compared with the 10-11% after endoscopic sphincterotomy.I,3 In support of this we cited the work of Glen and McSherry.4 Certainly, as Cotton points out, these workers had a failure after surgery of 4-48% (table vn, p. 32) but these data were from their original series dating back to 1932. We chose rather to use results from their much more recent study (table vi, p. 31) in which the overall frequency of residual calculi was less than 1% and that after duct exploration was 3-2%. We judged that the recent results gave a much fairer comparison with a modern treat-
were
1. 2.
such as endoscopic sphincterotomy. Other recent studies5 confirm our statement and the results of Glen and McSherry. Cotton also implies that we gave Kune6as a reference source for the overlooked stones, but this was not so: the quotation in our letter referred to surgical mortality and was completely
ment
Cotton, P. B. Lancet, 1979, i, 150. Blumgart, L. H., Wood., C. B. ibid. 1978, ii, 1249. 3. Safrany, L. ibid. p. 983. 4. Glen, F., McSherry, C. K m Current Problems in Surgery (edited by M. M. Ravitch and others). Chicago, 1975. 5. Lawson, R. A. M., Gunn, A. A. Jl R. Coll Surg. Edinb. 1970, 15, 222.
Cotton- cites our statement that the mortality for endoscopic sphincterotomy "is comparable with or, as Safrany3 argues, better than surgical mortality". In relation to mortality we cited Kune6 who had a mortality-rate of less than 2% and our
results in which the rate was 1.6%. Cotton argues this is relevant since comparisons should be made with the results of second or third surgical exploration. We agree, but should explain that previous surgery had been performed in 52% of our patients undergoing biliary-enteric bypass for stones. Judicious use of choledochoduodenostomy gives excellent results with a low incidence of complications in patients with dilated ducts and multiple calculi in whom the residual-stone rate (were it primary or secondary exploration) tends to be high.’ Certainly we did not intend to imply that endoscopic sphincterotomy was being used too frequently for gallstone removal. Perhaps we should re-emphasise the major point of our letter which was that the technique appears to be used frequently for primary papillary stenosis. A mortality-rate of 1-4% does not seem justifiable for the treatment of a condition which defies precise diagnostic description. When commenting on papillary stenosis it seems reasonable to try and prevent the waves of endoscopic enthusiasm washing up on the same shore as the receding tide of surgical endeavour in the same ill-defined area.
own
not
Department of Surgery, University of Glasgow, Glasgow G4 0SF
L. H. BLUMGART C. B. WOOD
A.F.P. AND CONGENITAL NEPHROSIS FINNISH TYPE
SIR,-Dr Spritz and colleagues’ report a case of congenital nephrosis Finnish type (C.N.F.) in which normal ot-fetoprotein (A.F.P.) was found in the amniotic fluid in the second trimester of pregnancy. Congenital and infantile nephrosis consists of heterogeneous group of renal diseases. We have used the name C.N.F. to separate a genetically, clinically, and pathologically uniform type of congenital nephrosis from similar disorders. Since there is no single pathognomonic change or finding in C.N.F. we have emphasised a combination of typical findings for the diagnosis of this disease. The main criteria include low birthweight, large placenta, proteinuria and oedema in the first weeks of life (usually at birth), failure to thrive, and typical histological findings.23 Spritz et al. based their diagnosis on the renal histology alone, although they mention the normal placenta as an atypical feature. The normal birthweight at term and the appearance of nephrotic findings at 5 months are further indicators that practically exclude C.N.F. in their case, despite the microcystic dilatations of proximal tubules in the kidney-biopsy specimen. The most likely explanation for the increased amniotic-fluid A.F.P. in C.N.F. is heavy fetal proteinuria.4 It is not to be expected in cases where the proteinuria first appears several months after birth. We agree with Spritz et al. that congenital nephrosis is a heterogeneous group of diseases and that this has to be taken into account when A.F.P. determination is planned for antenatal diagnosis. But we also suggest that the diagnosis of c.N.F. should not be made on insufficient criteria, because so far the 6. Kune, G. A. Current Practice of Biliary Surgery. Boston, 1972. 7. Madden, J. L. Surg. Clins N. Am. 1973, 15, 1095. 1. Spritz, R. A., Soiffer, S. J., Siegal, N. J., Mahoney, M. J. Lancet, 1978, ii, 1251. 2. Hallman, N., Rapola, J. in Pediatric Kidney Disease (edited by C. M. Edelmann, Jr); p. 711. Boston, 1978. 3. Huttunen, N-P. Archs Dis. Childh. 1976, 51, 344. 4. Aula, P., Rapola, J., Karjalainen, O., Lindgren, J., Hartikainen, A. L. Seppälä, M. Am. J. Dis. Child. 1978, 132, 984.
