THE SURGERY OF THE SPLEEN.

of 1 /1
870 GossE, from the Radium Institute, contains hopeful information concerning a widespread trouble. The medical uses of radium are undoubted, but the time has come when coordinated efforts are needed to evolve a standard technique. THE SURGERY OF THE SPLEEN. THE spleen is no doubt sometimes useful ; it is evidently not necessary; medicine supplies us with illustrations of how it may be harmful. The very lack of comprehensive knowledge of the part which is played by this curious organ in the physiology of the body lends interest to any observations which may be made in human beings who suffer from splenic disease. Very possibly, as has happened in connexion with other bodily structures in the past, the secrets of splenic function will ultimately be deduced by arguing backwards from pathological disturbances. Certain it is that much of the surgery of the spleen has been arrived at quite empirically by clinical observation. The discussion on the surgery of the spleen at the Rome Congress, briefly summarised in another column, brought out very well the position to-day. Operative treatment may be called for when the spleen has been injured, when it has become abnormally loosely connected with its lodgment, when it has been invaded by certain organisms or by the echinococcus, when it is the seat of true tumour formation, and in certain diseases associated with splenic enlargement or changes in the blood. In injuries splenectomy is the procedure of choice, even when the rupture is not large ; the organ does not allow of suture in general owing to its friability, and plugging a wound has been frequently followed by secondary haemorrhage or sepsis. Yet it must be borne in mind that loss of the spleen seems to be a more serious event for the child during its period of growth than for the adult. To combat the ill-effects in children after splenectomy, small transfusions of blood and the administration of splenic or bone- marrow extract have been recommended. When the spleen is abnormally mobile, fixation has brought relief to a number of patients, yet sometimes removal is the better course, and it is a necessary one when torsion of the pedicle has taken place. Abscesses of the spleen are usually best treated by incision and drainage, by the posterior thoracic route when they are at the upper pole, through the abdomen when at the lower one. Only very exceptionally, when the abscess has remained wholly intrasplenic, is removal of the organ the proper procedure. Most interest, however, circles around the question of splenectomy in those diseases of obscure pathology associated with splenic enlargement and usually with changes in the blood picture. The operation has been tried out sufficiently for us to be able to say definitely that it is absolutely called for in certain of these conditions and absolutely contra-indicated in others, whilst for some its value must remain doubt- ful until more results are collected. In splenic anaemia, which includes Banti’s disease, it is generally accepted that the results are extremely good, par- ticularly before hepatic cirrhosis has come on, but MAYO recommends that the operation should be performed even in the terminal stage as, after it, some patients have got well and lived for years. In haemolytic jaundice operation is demanded only in the acquired disease and the recovery is usually symptomatically complete and permanent, though the fragility of the red corpuscles may remain. In Gaucher’s disease it appears very doubtful whether splenectomy influences very much the course of the malady. In pernicious anaemia the operation has been well spoken of by certain surgeons, and the mortality has been very much reduced by careful selection of the time to intervene and the assistance of blood transfusions. Although transient improvement appears to have followed, it does not seem that the progressive course of the disease has been really affected to an appreciable degree. Splenectomy in purpura hsemorrhagica has produced striking, almost dramatic, results in rapidity of cure and its permanency. The former belief that this depends upon a restoration to normal of the blood platelet count would, however, seem to have been disproved by the experience of BRILL and ROSENTHAL in two cases under their care, for the platelets did not increase in number, yet the patients were cured. Leuk2emia has for long been regarded as a disease in which surgery was contra- indicated, but MAYO, in 1924, reported that three patients had lived more than five years and eight for more than three after removal of the spleen ; more- over, the danger of the operation has been considerably reduced by previous X ray exposures. Perhaps in the more chronic type of the disease surgery is justifiable and called for. Many problems connected with the spleen remain unsolved. There is, for all practical purposes, only one surgical procedure possible in the treatment of its diseases-namely, its ablation. The scope of surgery is, therefore. obviously limited. Operative treatment will remain the method of choice in those conditions which arise in the spleen itself, whilst it can be no more than alleviative where the splenic condition is secondary. Only further study in the future will enable us to classify splenic diseases into these two categories correctly. HELP IN CHOOSING A CAREER. UNTIL very recent years, and even yet to a quite large degree, the choice of employment for a child leaving school has been determined by personal liking, parental suggestion, tradition (as typically in the mining and fishing industries), or opportunity. There has been, however, for some time a growing tendency on the part particularly of large industrial firms to make a selection by some method of testing of the most suitable types for their special work, and, on the other hand, on the part of educational and other authorities to discover for what work any particular child is best suited. Vocational selection and vocational guidance thus represent two distinct movements with one end in view. The construction of new intelligence tests, especially those of a non-linguistic type, has greatly contributed to these movements and has at the same time been fostered by them. The most complete and systematic study of methods applicable to vocational guidance that has so far appeared has just been issued by the Medical Research Co’tlllci1.1 The work was carried out by the Industrial Fatigue Research Board and the National Institute of Industrial Psychology, and consisted of an intensive study of 100 children (52 boys and 48 girls), who were due to leave school within a year. The main object of the study was to determine the best methods of testing for the purposes of vocational guidance, but in addition, actual advice was given to the parents on the basis of the results obtained, and a further inquiry was made two years later in order to dis- cover the wisdom or otherwise of the advice given. The methods used were therefore largely experi- mental, and further research may lead to very con- siderable modifications. That the work was under 1 A Study in Vocational Guidance. H.M. Stationery Office. 1926. 4s.

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870

GossE, from the Radium Institute, contains hopefulinformation concerning a widespread trouble. Themedical uses of radium are undoubted, but thetime has come when coordinated efforts are neededto evolve a standard technique.

THE SURGERY OF THE SPLEEN.THE spleen is no doubt sometimes useful ; it is

evidently not necessary; medicine supplies us withillustrations of how it may be harmful. The very lackof comprehensive knowledge of the part which is

played by this curious organ in the physiology of thebody lends interest to any observations which maybe made in human beings who suffer from splenicdisease. Very possibly, as has happened in connexionwith other bodily structures in the past, the secretsof splenic function will ultimately be deduced byarguing backwards from pathological disturbances.Certain it is that much of the surgery of the spleenhas been arrived at quite empirically by clinicalobservation. The discussion on the surgery of thespleen at the Rome Congress, briefly summarised inanother column, brought out very well the positionto-day. Operative treatment may be called for whenthe spleen has been injured, when it has become

abnormally loosely connected with its lodgment,when it has been invaded by certain organisms or bythe echinococcus, when it is the seat of true tumourformation, and in certain diseases associated withsplenic enlargement or changes in the blood. In

injuries splenectomy is the procedure of choice, evenwhen the rupture is not large ; the organ does notallow of suture in general owing to its friability, andplugging a wound has been frequently followed bysecondary haemorrhage or sepsis. Yet it must beborne in mind that loss of the spleen seems to be amore serious event for the child during its period ofgrowth than for the adult. To combat the ill-effectsin children after splenectomy, small transfusions ofblood and the administration of splenic or bone-marrow extract have been recommended. When the

spleen is abnormally mobile, fixation has broughtrelief to a number of patients, yet sometimes removalis the better course, and it is a necessary one whentorsion of the pedicle has taken place. Abscesses ofthe spleen are usually best treated by incision anddrainage, by the posterior thoracic route when theyare at the upper pole, through the abdomen when atthe lower one. Only very exceptionally, when theabscess has remained wholly intrasplenic, is removal ofthe organ the proper procedure.Most interest, however, circles around the question

of splenectomy in those diseases of obscure pathologyassociated with splenic enlargement and usually withchanges in the blood picture. The operation hasbeen tried out sufficiently for us to be able to saydefinitely that it is absolutely called for in certain ofthese conditions and absolutely contra-indicated inothers, whilst for some its value must remain doubt-ful until more results are collected. In splenicanaemia, which includes Banti’s disease, it is generallyaccepted that the results are extremely good, par-ticularly before hepatic cirrhosis has come on,but MAYO recommends that the operation should beperformed even in the terminal stage as, after it,some patients have got well and lived for years. In

haemolytic jaundice operation is demanded only inthe acquired disease and the recovery is usuallysymptomatically complete and permanent, thoughthe fragility of the red corpuscles may remain. InGaucher’s disease it appears very doubtful whether

splenectomy influences very much the course of themalady. In pernicious anaemia the operation has beenwell spoken of by certain surgeons, and the mortalityhas been very much reduced by careful selectionof the time to intervene and the assistance ofblood transfusions. Although transient improvementappears to have followed, it does not seem that theprogressive course of the disease has been reallyaffected to an appreciable degree. Splenectomy inpurpura hsemorrhagica has produced striking, almostdramatic, results in rapidity of cure and its permanency.The former belief that this depends upon a restorationto normal of the blood platelet count would, however,seem to have been disproved by the experience ofBRILL and ROSENTHAL in two cases under their care,for the platelets did not increase in number, yet thepatients were cured. Leuk2emia has for long beenregarded as a disease in which surgery was contra-indicated, but MAYO, in 1924, reported that threepatients had lived more than five years and eight formore than three after removal of the spleen ; more-

over, the danger of the operation has been considerablyreduced by previous X ray exposures. Perhaps in themore chronic type of the disease surgery is justifiableand called for.

Many problems connected with the spleen remainunsolved. There is, for all practical purposes, onlyone surgical procedure possible in the treatment ofits diseases-namely, its ablation. The scope of

surgery is, therefore. obviously limited. Operativetreatment will remain the method of choice in thoseconditions which arise in the spleen itself, whilst itcan be no more than alleviative where the spleniccondition is secondary. Only further study in thefuture will enable us to classify splenic diseases intothese two categories correctly.

HELP IN CHOOSING A CAREER.UNTIL very recent years, and even yet to a quite

large degree, the choice of employment for a childleaving school has been determined by personalliking, parental suggestion, tradition (as typicallyin the mining and fishing industries), or opportunity.There has been, however, for some time a growingtendency on the part particularly of large industrialfirms to make a selection by some method of testingof the most suitable types for their special work,and, on the other hand, on the part of educationaland other authorities to discover for what workany particular child is best suited. Vocationalselection and vocational guidance thus representtwo distinct movements with one end in view. Theconstruction of new intelligence tests, especiallythose of a non-linguistic type, has greatly contributedto these movements and has at the same time beenfostered by them.The most complete and systematic study of methods

applicable to vocational guidance that has so farappeared has just been issued by the Medical ResearchCo’tlllci1.1 The work was carried out by the IndustrialFatigue Research Board and the National Instituteof Industrial Psychology, and consisted of an intensivestudy of 100 children (52 boys and 48 girls), who weredue to leave school within a year. The main objectof the study was to determine the best methods oftesting for the purposes of vocational guidance,but in addition, actual advice was given to the parentson the basis of the results obtained, and a furtherinquiry was made two years later in order to dis-cover the wisdom or otherwise of the advice given.The methods used were therefore largely experi-mental, and further research may lead to very con-siderable modifications. That the work was under

1 A Study in Vocational Guidance. H.M. Stationery Office.1926. 4s.