1062

size to the state of the placenta ; but cases of the

type described by WRiGLEY are a distinct entityand may lead to great difficulty in delivery unlessrecognised in time.

Unfortunately we still have no means of inducinglabour immediately and without risk. Though themembranes be ruptured, labour may not begin ina day or even a week. What is then to be done ?BRow--B-E 26 believes that, where the foetus is of thirty-four or more weeks’ maturity and is normal, labourshould never be induced surgically, unless the obste-trician is prepared to undertake caesarean section ifdelivery is not imminent after forty-eight hours.But some of those who would follow such a coursefor urgent induction because of maternal disorder,such as pre-eclamptic toxaemia, might neverthelesshesitate to adopt it for a normal person, anyhow inthe fortnight after the expected date of confinement.The question here is not only when to induce labour,but also the lengths to which we should go when thesimplest methods do not succeed. More precisemethods of detecting ageing of the placenta wouldenable us to select more rationally cases for prompt.induction of labour.

26. Browne, J. C. McC. Proc. R. Soc. Med. 1952, 45, 532.27. Kremen, A. J., Linner, J. H., Nelson, C. H. Ann. Surg. 1954,

140, 439.28. Weckesser, E. C., Ankenny, J. L., Portman, A. F., Price, J. W.,

Cebul, F. A. Surgery, 1951, 30, 465

Annotations

NUTRITION AFTER MASSIVE INTESTINALRESECTION

THE time may come when the man with a middle-agedspread will present himself to the surgeon before seekinga life-assurance policy. Kremen et a1.27 have found thatin dogs removal of the distal half of the small bowel isfollowed by lowered fat absorption and loss of weight,whereas removal of the proximal half has no such effect.In the clinical field, Henrikson excised part of thesmall bowel with the aim of correcting obesity, but thepatient lost so much weight that it was difficult tostrike a balance. Again in man, Kremen has added atouch of finesse by excluding, rather than excising, allbut the terminal eighteen inches of the lower half ofthe small bowel; the excluded portion, opening distallyinto the transverse colon, is kept in abdominal store,as it were, so that if too much weight is being lostsegments can be returned to activity by later operations.Accordingly the patient may eat to his stomach’s contentand yet continue to lose weight. It seems that the

absorption of fats may be affected selectively. Weckesserand Ankenny found that in dogs in which the distaltwo-thirds of the small intestine had been removed

nitrogen was lost in the feces but to a lesser degree thanfats, while carbohydrate excretion was unaffected 2B; butKremen et al. found that the amount of nitrogen lostwas to some extent linked to the fat excretion.

Assessment of intestinal function is difficult sincethere is always a discrepancy between the results of

absorption tests and the outcome of balance studies.Absorption tests are done individually for one of the threefundamental food elements, and a full load of thesubstance under investigation (methionine, for instance,if proteins are being considered) is given in a test dose.The gut may not be able to assimilate large quantitiesof such a substance, which it would receive in moredilute form in balance studies. Weckesser and Ankenny 2 11tried the effect of vagal section on dogs after removal

of two-thirds of the small intestine. Fat absorption wasincreased only if vagotomy was done soon after resection ;this effect seemed to be unrelated to the transit time-which is hardly surprising since in idiopathic steator.rhoea every opportunity for absorption is given to thegut by a natural delay in transit.

It is unlikely that many surgeons will seriously considerresecting the small intestine for obesity ; but from timeto time the problems of this operation come their warbecause, for example, of extensive mesenteric throm.bosis requiring wide resection, or Crohn’s disease requiringrepeated resections. Haymond 29 surveyed 257 patientswho for one reason or another had undergone massiveresection of the small intestine. Diarrhoea was thecommonest sequela ; this was often severe and evenled to death. It was best controlled by reducing thefat intake, maintaining the protein balance, and givingplenty of carbohydrate. His finding that 50% is theupper limit for the amount of small bowel that may besafely removed accords with the experimental findingsof Kremen and his colleagues, and with those of

Trzebicky 30 and Monari 31 many years earlier.

29. Haymond, H. E. Surg. Gynec. Obstet. 1935, 61, 693.30. Trzebicky, R. Arch. kiln. Chir. 1894, 48, 54.31. Monari, U. Beitr. klin. Chir. 1896, 16, 479.32. Sharp, M. U. The Social Problems of Young Disabled Persons

and Long-Stay Hospital Patients in Kent. Report submittedto the Leverhulme Research Awards and the South EastMetropolitan Regional Hospital Board. 1954. Pp. 14.

THE YOUNG DISABLED

WHAT with reablernent centres, disablement resettle-ment officers, the quota, Remploy, disability pensions,and the rest, we are apt to think we are doing reasonablywell by the disabled. But Mrs. Sharp,32 surveying thesocial problems of the young disabled in Kent, foundthe needs of many of them so pressing that she couldnot merely record them and pass them by : in threeout of every four homes which she visited she eithergave much-needed advice herself or referred the haiidi-capped person to appropriate agencies.

She confined her survey to people aged between 15

and 45, and deliberately excluded all those disabled byblindness, deafness, epilepsy, mental defect, psychosis,or pulmonary tuberculosis, and all who were in full-timeemployment. She found a gap in our service for thedisabled at the outset : she had great difficulty in

discovering them. None of the bodies who had to dowith them maintained a complete list of disabled people.Thanks, however, to the help of 17 voluntary societies,2 disabled people’s clubs, the Kent County Council, theNational Assistance Board, and the Ministries of Pensionsand Labour, she was given introductions to 576 peoplewith disabilities, and in addition 65 long-stay patientswere referred to her by hospitals. Of this total of 641.419 were suitable for inclusion in the survey-212 menand 207 women.

Of the 65 hospital patients, 25 were in four small unitsreserved mainly for younger patients by the regionalhospital board. Of the remaining 40, dotted about the

county, only 14 wished to be moved so that they could enjoyyounger company. The rest wanted either to stay near theirrelatives, or to go on getting some special treatment for theirdisabilities, in the hospitals where they were already patient.Places were found in the special units for 4 of those whowished for transfer ; but since there were no more placesavailable, plans are being considered for collecting the rest

in some other centre.

Mrs. Sharp believes that most young patients, if theywere given the choice on admission, would prefer to be esent among their contemporaries, where they could hopefor more liveliness and companionship than is possiblein a chronic ward. And such companionship might wellsave some from the frustration which turns them intodifficult characters as the years go by.