OPERATIVE MANAGEMENT OF

Transcription

1 OPERATIVE MANAGEMENT OF HAEMATEMESIS AND MELAENA With special reference to Bleeding from Oesophageal Varices Lecture delivered at the Royal College of Surgeons of England on 8th April 1957 by Norman C. Tanner, M.D., F.R.C.S. Surgeon, Charing Cross Hospital Senior Surgeon, St. James' Hospital, Balham THEMR ARE FEW operations in gastro-enterology that present so many technical problems as the management of haematemesis and melaena. While nothing is quite so valuable as the experience gained in operating on or assisting at operations on such cases, many problems repeat themselves time and again, and much can be gained from discussing methods of avoiding, circumventing or overcoming various difficulties. It is not intended to discuss anew the indications for operation and instead attention will be focused on methods of dealing with the situation, once the decision to operate has been made. We may divide our cases broadly into three categories: 1. Cases with a past history suggesting peptic ulcer. 2. Cases with no past history suggestive of ulcer. 3. Cases of known or suspected portal hypertension. GROUPS 1 AND 2, IN BOTH OF WHICH A PEPTIC ULCER IS THE LIKELIEST CAUSE OF BLEEDING The first two groups can be considered together. Their main difference will be that with a good history of chronic peptic ulceration, surgery will be embarked on early. In cases where there is little or no ulcer history the decision to operate will usually only be made if there is a severe repetition of bleeding after the patient has come under treatment or if there is evidence of persistent bleeding. They have in common the fact that at operation particular attention will be paid to the stomach and duodenum, as being the likeliest source of origin of the bleeding. In patients with a history of oesophageal ulceration, truly massive bleeding rarely occurs except when the aorta or heart chambers are eroded and such cases rarely survive long enough to come to surgery. In cases with massive bleeding and oesophageal ulcer it is important to remember the frequent coexistence of oesophageal and duodenal or gastric ulceration, and in such cases a duodenal or gastric ulcer will not infrequently be found to be the site of the bleeding. Pre-operative preparation Occasionally the bleeding may be so uncontrollable, as for example when the splenic artery has been eroded, that the patient has to be sent to the operating theatre with no more preparation than the setting up of 30

2 OPERATIVE MANAGEMENT OF HAEMATEMESIS AND MELAENA one or more intravenous blood drips in order to maintain a sufficient blood pressure to move the patient to the theatre. It is doubtful whetherintra-arterial transfusions have any very great advantages in such cases. In the majority of cases each bleeding will be followed by a period of temporary arrest and improving condition. In such cases a few hours of slow drip transfusion is well worth-while, but undue delay is unwise as it may be followed by a recurrence of bleeding. The final stages of resuscitation are best carried out in the operating theatre ante-room. After morphia has been given a catheter should be passed via the nares into the stomach in order to remove any excess of blood or gas. The tube will not remove blood clots, and the probable presence of clots in the stomach must be remembered by the anaesthetist, for at times blood and clot may be vomited and inhaled. In patients with coincident ulcer perforation and bleeding there will be more urgency, but time should be taken to overcome pain and shock by the use of morphia, intravenous blood and plasma, and gastric aspiration. In cases with coincident duodenal or pyloric obstruction the stomach must be carefully decompressed and gently irrigated with a cold saline solution. The blood chloride and, if there is any suggestion of tetany, the calcium levels should be restored to normal prior to operation by intravenous saline infusion and calcium gluconate injections. The anaesthetic Either local or general or even in some cases a spinal anaesthetic may be used. General anaesthesia is most commonly favoured. The writer, however, uses local anaesthesia. It is possible to start the anaesthesia while the patient is still very ill, the dangers of blood inhalation are minimized and as many of the patients are elderly they are particularly suitable subjects for this form of anaesthesia. It is important to produce an efficient field block anaesthesia. Several of the modern local anaesthetic drugs can be relied upon to last two or more hours. Local anaesthesia is less well suited to the young, robust or obese. The operative approach A generous abdominal incision must be made, particularly when operating under local anaesthesia. It is however wise, if using local anaesthesia, not to extend the incision lower than the umbilicus, in order to prevent evisceration when the patient talks or coughs. An upper abdominal incision is used. The writer makes a mid-line supra umbilical incision as high as the xiphoid process for most cases. If a deeply placed duodenal ulcer is present, particularly in an obese patient, there should be no hesitation in making a transverse extension of the incision into the right flank in order to obtain easy manipulation of the duodenum. Rarely, extension of the incision by removal of the xiphoid process, 31

3 NORMAN C. TANNER sternal splitting or extension into one of the left intercostal spaces may be required to deal with a high lying ulcer. THE OPERATIVE MANAGEMENT OF THE BLEEDING LESION On opening the abdomen, if local anaesthesia is used, a further injection of local anaesthetic solution is made. This may be made either directly into the splanchnic region, or into the tissues round the main vessels supplying the stomach near their origin, round the middle colic artery and into the upper jejunal mesentery near its attachment to the posterior parietes During the opening of the abdomen, excessive bleeding from the wound or the presence of enlarged veins in the ligamentum teres will be noted as indicating the possibility of portal hypertension. Additional evidence of hypertension may be given by the escape of ascitic fluid, by the appearance and texture of the liver and by splenomegaly. The colon and upper jejunum should be inspected, sometimes blood in its lumen can be detected through the wall. Whether there is evidence of portal hypertension or not, the stomach and duodenum are now carefully palpated and inspected. In some cases an ulcer will be immediately obvious, but even so the whole stomach and duodenum should be examined. The pyloric antrum and pylorus, and then the first part of the duodenum is palpated and inspected. Next a retractor is placed under the liver and the anterior surface of the upper stomach is examined, and then the oesophageal hiattus and any parts of the oesophagus which can be felt. If no definite ulcer or tumour is found an opening is made through the tenuous lesser omentum (hepato-gastric ligament) and the posterior wall of stomach and duodenum palpated, taking especial care to free any adhesion to the posterior wall of the upper stomach in order to examine this part fully. Both greater and lesser curve parts of the stomach must be studied, and then the stomach and duodenum rotated in order to inspect the posterior surfaces. A small ulcer may be indicated by a local thickening or rigidity, perhaps with a tiny thickened vessel end in its middle feeling like a short bristle. It is very easy to overlook these minute evidences of ulcer. Local scarring, congestion, enlarged lymph nodes, failure of mucosa to slide over the muscularis, prestenotic diverticula are other evidences of the presence of ulcer. Soft adenomata may be almost indistinguishable from gastric folds. Leiomyomata are usually distinct enough not to be mistaken for blood clot and an ulcer may be felt in the leiomyoma. Most carcinomas of the stonlach which present with massive bleeding are advanced, but occasionally they are small and may be difficult to distinguish from simple ulceration. If this examination is negative then a careful examination of the rest of the abdominal viscera is to be carried out. The second and third part of the duodenum are examined for post bulbar ulcer, or carcinoma 32

4 OPERATIVE MANAGEMENT OF HAEMATEMESIS AND MELAENA of the ampulla of Vater. If there has been a recent history of burns, a simple ulcer of the second part of the duodenum (Curling ulcer) or even in the jejunum may be found. The gall bladder is examined to see if it contains blood or a bleeding tumour and the branches of the coeliac artery are palpated for aneurysm. The pancreas is examined with care as either pancreatitis or pancreatic carcinoma are occasional causes of bleeding. The aorta is examined for aneurysm and calcification. In a recent case of the writer's the cause of repeated and finally fatal bleeding was a leak from a dissecting aortic aneurysm into a small opening in the third part of the duodenum (Fig. 1). Next the jejunum, ileum and colon are palpated throughout their length and inspected where possible, looking particularly for the level at which intraluminal blood is present, for local or diffuse haemangiomas, simple or malignant tumours, inflammatory lesions and diverticula. Should a Meckel diverticulum be found it is examined for signs of ulceration in or near it. The ovaries and pelvic organs are examined for Krukenberg or other tumours. If no adequate cause for the bleeding is found then re-examination of Fig. 1. A probe demonstrates a fistula leading from a dissecting aortic aneurysm into the third part of the duodenum. 33

5 NORMAN C. TANNER the stomach and duodenum is made. If there had been a satisfactory pre-operative gastroscopy there will usually be no advantage in opening the stomach to inspect and palpate its interior, but if there is any doubt at all the interior should be examined. The pyloric region is one where small chronic ulcers can at times escape detection and so the gastrotomy Fig. 2. A small ulcer with an open vessel end almost filling the crater. This gives the appearance of being an acute ulcer at operation, but in fact had an eight years' history. should be a longitudinal incision extending from the pyloric antrum into the duodenum. This should be widely opened and the interior meticulously examined for scars, ulcers or gastritic erosions. A finger should be passed up into the direction of the oesophagus and down into the second part of the duodenum. If a small acute ulcer is found I am in favour of gastrectomy, preferably Billroth I, although there are some who advocate local resection for such lesions because of their lack of chronic symptoms and the possibility that this minor procedure may give subsequent long-standing relief. It is, however, not always certain that such lesions are solitary and some which appear acute may in reality be small chronic ulcers (Fig. 2). If a chronic ulcer is found most authorities are now agreed that it is advisable to carry out a partial gastrectomy. Lesser operations have at times been advocated, e.g., local excision of gastric ulcers, or ligature of the bleeding point and gastro-jejunostomy for duodenal ulcer, but these, have a lower su.ccess rate in stopping the bleeding and a _higher 34

6 OPERATIVE MANAGEMENT OF HAEMATEMESIS AND MELAENA chance of recurrent bleeding than partial gastrectomy. However, such operations are certainly permissible if the surgeon feels that gastrectomy would be impracticable in his hands. The writer had carried out gastrojejunostomy and ligature of the bleeding point by duodenotomy ten times for severe bleeding duodenal ulcer up to ten years ago. Two patients bled again within a week and one died of haemorrhage, but eight did well. The technical difficulties of resection, particularly of bleeding duodenal ulcer, may be extreme. Generally speaking, it is unwise to tackle these cases unless the surgeon has a wide experience of dealing with difficult duodenal ulcers. Occasionally the less experienced surgeon may be driven to operate on such cases, and under these circumstances palliative procedures, local excisions, sleeve resections, etc., will at times be the wiser choice. If a gastric ulcer penetrating the pancreas is the cause of bleeding, it is at times found that the splenic artery is eroded completely and bleeding may come freely from both exposed ends and both will need ligature. The most difficult type of duodenal ulcer is the posterior ulcer penetrating the pancreas. The ulcer should be exposed by transecting the duodenum at ulcer level and then separating the posterior edges of the duodenum from the crater edge (Fig. 3). At times bleeding from a vessel in the crater is seen to be actively in progress making visualisation difficult. In such cases a strong small needle should be threaded with stout linen or silk and the bleeding point underrun without being over-concerned Fig. 3. A bleeding posterior duodenal ulcer. The duodenum is transected at ulcer level and then the posterior part of the duodenum is separated from the right edge of the ulcer by sharp dissection and the duodenum closed. about the position of the pancreatic or bile ducts. These will in fact be but rarely encroached upon and too great a concern for them may lead to repeated inadequate attempts to stop the bleeding with consequent deterioration of the patient. It is at times easier to suture the ulcer edges together with or without a tampon of algenate gauze in the crater than to underrun the bleeding point. Should the bile duct have inadvertently been occluded by the suture it would be necessary to carry out a short circuit of the gall bladder to bowel during the convalescence, but in fact I have never seen such damage produced. It is however usually found, on exposing the ulcer crater, that bleeding is temporarily arrested and a 35

7 NORMAN C. TANNER soft clot lies in some part of the crater. Full advantage of this desirable state of affairs should be taken. On no account should a swab or a sucker be placed near the clot, which may in fact be a loosely clotted aneurysm, for this may start off alarming bleeding. Instead the clotted area should be gently underrun with a strong ligature before proceeding further with the dissection. The further duodenal dissection does not differ materially from that of non-bleeding ulcer. The main principle will :~~~~~~~~~~~ be to dissect up a very short distance beyond the crater on the posterior wall-lcm. is adequate, Fig. 4. If there is enough mobilized duodenum, a purse string suture is introduced, though there is often insufficient for this. In any case the closure is completed by suturing the left edge of the crater to the duodenum, thus reinforcing the suture line and burying the closed duodenal end in the ulcer crater. and then suture the anterior and posterior walls together carefully. The suture line is, if possible, invaginated by a further suture line and finally a row of sutures is placed between the anterior duodenal wall and proximal or left edge of the ulcer crater so that the closed duodenal end is finally pressed snugly into the ulcer crater and on to the bleeding area (Fig. 4). A drain should be put down to the site of closure if there is any doubt at all as to its safety, or if there is any suspicion that the ulcer is deep enough to have eroded a pancreatic duct. Post-bulbar ulcer At times the ulcer will be in or involve the post-bulbar region and its base apparently overlying the bile duct. In such a case, if its probable difficulties are discovered before the duodenal dissection is begun, a palliative or pre-ulcer closure may be used. A catheter attached to a sucker is gently inserted into the duodenum via an opening made in the anterior gastric wall. If it is found that clear bile or duodenal juice is aspirated it can be assumed that bleeding is temporarily arrested. Under such circumstances a prepyloric division of the stomach, removing the antral mucosa, may be made (Tanner, 1951). Very rarely the first part or bulb of the duodenum is sufficiently unscarred to transect and close the duodenum proximal to the ulcer and distal to the pylorus. There is, of course, not quite the same certainty of preventing recurrent bleeding by this procedure. I believe that ulcer healing occurs very rapidly-in 36

8 OPERATIVE MANAGEMENT OF HAEMATEMESIS AND MELAENA a matter of days after in most cases, but in one of my cases treated in this way recurrent bleeding occurred because, although the ulcer had practically healed, an aneurysm was present, which bled again on the seventh post-operative day (Tanner, 1954) (1). Stomal ulcer If a bleeding stomal ulcer is found, treatment may be varied. If the stomal ulcer follows posterior gastro-jejunostomy, the anastomosis may be dismantled and gastrectomy carried out, providing the patient is fit and the surgeon very experienced. Alternatively, the ulcer may be approached by anterior gastrotomy and the crater sutured over. Sometimes local excision of a jejunal ulcer is simpler. If the stomal ulcer follows a gastrectomy, local excision or suture of the crater, or a higher resection, may be required. If feasible a vagotomy should be added. In the event of no likely cause for the bleeding being found, the surgeon is left in a quandary. In the past, either nothing has been done, or less radical measures used, e.g., tying the right and left gastric and right and left gastro-epiploic arteries, hoping thereby to reduce the gastric blood flow, at least temporarily. These measures may be followed by success in some cases, but if the bleeding is really severe, it continues or recurs after a short period in a high proportion of the cases. The late Professor H. Finsterer was a firm advocate of partial gastrectomy for these cases. The idea behind the gastrectomy is that there may be an impalpable bleeding lesion in the stomach or duodenum and an orthodox partial gastrectomy removes those parts of the stomach and duodenum most commonly affected by peptic ulceration. Even if the bleeding should have -come from multiple gastric erosions the gastrectomy would probably remove many of them and would diminish the blood supply to the remaining part of the stomach. It is not uncommon after these " blind " operations to find the causative lesion in the excised stomach, a very gratifying confirmation of the correctness of the procedure. As a result of the accumulated experience of such cases it is now generally conceded that a partial gastrectomy is the correct procedure, provided that the haemorrhage was " massive" and that a very careful examination of the abdominal viscera had failed to find any other causative lesion. This has been the writer's practice for some years and has proved a satisfactory one. Its failures have been, one case of diffuse erosive gastro-entero-colitis where bleeding continued from the colon, second was the case already mentioned where there was a fine fistulous communication between a dissecting aortic aneurysm and the third part of the duodenum, and the third a patient whose bleeding ulcer turned out to be 4cm. from the cardia on the greater curvature! Persistence of bleeding despite gastrectomy Despite gastrectomy bleeding may persist, particularly in cases where no causative lesion or a diffuse gastritic lesion was found. Patients 37

9 NORMAN C. TANNER with haematemesis include a percentage of cases with defective power of blood clotting and so moderate degrees of suture line bleeding are commoner after gastrectomy for patients who have a history of recurrent haematemesis than in those with a history of pain only. Therefore the first treatment should be supportive and preferably the transfusion of fresh blood. If bleeding persists to a dangerous extent despite this, it may be assumed that bleeding is taking place from the remaining stomach and that more active measures will be required. Theoretically a total gastrectomy will be required, but in view of the dangers and disability of this operation a " quasi-total" gastrectomy is preferable. This should be a resection of all but a cuff of stomach some 2cms. long round the cardia. By leaving this cuff the risks of the gastrectomy are reduced, probably to less than a quarter of the risk of total resection. The operation is easier, and in most patients can be carried out through an abdominal incision. In addition, the cardia mechanism is less disturbed than with a total gastrectomy and so biliary regurgitation is less likely to be troublesome later. It is probable too that even this small segment of stomach may be enough to delay the onset of macrocytic anaemia. This small segment of stomach will be highly unlikely to secrete enough digestive juice to lead to further ulceration. In one of the writer's cases this operation disclosed a bleeding lesion which had missed the previous resection, the ulcer being only 4cm. from the cardia on the greater curvature side. Post-operative care Patients operated on in a state of severe anaemia are more prone to post-operative infective complications than patients who are not anaemic. Therefore after operation slow drip transfusions should be given until a reasonable blood haemoglobin level is obtained, 65 per cent. at least. In addition it may be wise, particularly in elderly patients, to use an antibiotic prophylactically. BLEEDING OESOPHAGEAL VARICES In cases where oesophageal varices are bleeding, the lesion will usually have been suspected previously and treated by the use of an intragastric balloon. The inflated balloon is pulled against the cardia in order to compress the veins and so cut off the communication between the hypertensive portal veins and the oesophageal veins. The pressure in the oesophageal varices thus diminishes, so slowing the bleeding and favouring clotting. On deflating or removing the balloon it is not uncommon for bleeding to recur, and the balloon may have to be reinflated. As a result of prolonged traction on the nasal catheter, local necrosis round the nares may occur. Liver failure is often precipitated by the anaemia and pneumonia from inhalation of blood by the debilitated and narcotised patient not infrequently leads to death. The writer's opinion is now that if bleeding 38

10 OPERATIVE MANAGEMENT OF HAEMATEMESIS AND MELAENA recurs when the balloon is deflated at the end of twenty-four hours' traction, then it should be reinflated and the patient prepared for urgent operation. The nature of the operation For many years there has been considerable thought and experiment to try and find an operation which would arrest bleeding from oesophageal varices. The older operations of splenectomy, tying the splenic and left gastric arteries, or ligature of the left gastric vein are rarely followed by success. Direct attacks on the veins by injecting the varices with sclerosing solutions is obviously unsuitable during the acute phase of bleeding. Even as an interval operation the writer found the procedure disappointing in a trial of several cases some fifteen years ago, though a few encouraging reports have been made. The swallowing of anticoagulants, buffered thrombin, gelfoam, etc., is not of help. Phemister recommended resection of a length of the oesophagus and cardia as a means of arresting bleeding from varices. This is a somewhat formidable procedure, but it has been followed by a good measure of success, which in many cases is longlasting. In 1950 the writer made a more direct attack on the varices as an interval operation. A longitudinal incision was made through the muscularis of the lowest oesophagus and then a running suture of catgut was passed all round the circumference of the mucosa (after separating it from the muscular layer). As this was followed by another haemorrhage two months later the procedure was not used again. A similar method is used by I. Boerema (1949) and G. Crile, Jr. (1953), who sew up the lowest varices rather as they would treat piles. Using a transthoracic approach through the eight rib bed, an incision one inch long is made into the oesophagus, two inches above the cardia. On holding the gullet open three groups of varices are seen which project into the stomach. Each varix is obliterated by a running suture, and Crile recommends that the suture be continued down until gastric mucosa is reached and as high in the gullet as can be reached through the incision. This method is effective for acute bleeding and has the advantage of having a much lower mortality than oesophago-gastric resection. On the other hand, in cirrhotic cases its effect appears to be only temporary, for R. R. Linton (1953) found that bleeding recurred in five out of fourteen Boerema- Crile operations between two weeks and five months after operation. It is remarkable how readily hypertension in varices recurs if any vascular connexion remains between the portal and azygos veins and so this operation, which leaves many minor oesophageal veins untouched, will have only a temporary effect, but it is useful as an emergency procedure. The writer has always aimed at achieving a method of dealing with the varices locally which would not only arrest acute bleeding but also have some success in preventing later bleeding. An operation of this sort is 39

11 NORMAN C. TANNER particularly desirable for the patient who is unsuited for any form of porto-caval venous shunt, e.g., the so-called post-splenectomy bleeder who has no satisfactory portal vein. I have always been attracted by the idea of making a complete surgical division between the veins of the portal and of the azygos systems below the cardia, in order to reduce the pressure in the oesophageal varices to that of the azygos vein. I first used the operation which I called transgastric porto-azygos disconnexion, in which the mid stomach is transected and resutured, after having divided all the vasa brevia and the branches of the left gastric vein which drain the stomach above the line of transection (Tanner, 1950). Unfortunately, some three or four of the cases eventually bled again. It was found by post-mortem injection methods that there was no appreciable flow across the gastric suture line eighteen months after transection and resuture, but venous connexions between the oesophageal veins and inferior phrenic veins around the cardia kept the pressure up in the varices, presumably because the inferior phrenic veins had become hypertensive. Therefore I modified the operation and since 1951 have carried out what is now a subcardiac porto-azygos interruption as follows (Tanner 1954) (2) Ḃy an abdomino-thoracic approach the lower 5cm. of the oesophagus, the cardia, the upper 5cm. of greater and lesser curve of the stomach are Fig. 5. Diagram showing the method of cutting all venous communications between the oesophageal veins and the portal branches. entirely freed from all external vascular connexions. The stomach is then completely transected 5cm. below the cardia and firmly resutured. (Figs. 5 and 6). There is just enough blood supply from the oesophagus 40

12 OPERATIVE MANAGEMENT OF HAEMATEMESIS AND MELAENA to nourish the small upper gastric segment. This operation has effected a considerable improvement in our results in cases of persistent or catastrophic acute bleeding. It has also proved a valuable interval operation. In all, some eleven cases of acutely bleeding oesophageal varices have been treated by this procedure with cessation of bleeding in each case. Some months later minor bleeding occurred in two cases and a fatal one :~~~~~~~~~ ~~~~~~~~~~~~~~~...Q- Fig. 6. At the completion of the operation most of the small upper segment of stomach is hidden by the wide Lembert stitching. in a third. This latter was due to a gastric ulcer which had appeared at the suture line. Against my usual practice I had made the anastomosis with silk. Since using catgut for this layer, no further suture line ulcers have been encountered. In addition, the operation has been used as an interval operation on many cases with excellent long term effects. The operation may be followed by some degree of post-vagotomy gastric stasis, and a pyloroplasty had to be carried out subsequently in two cases to correct this. In the rest of the cases a few days' gastric suction has been sufficient to avoid any serious post-vagotomy complications. It might be expected that ascites might follow the severence of several large venous anastomotic channels. In fact there has been only a minor 41 4

13 NORMAN C. TANNER difficulty in two cases. It has been no more common than after portocaval anastomosis where it may appear as a transient complication. A shunting operation between the portal and caval systems is a most valuable interval operation for oesophageal varices, but has the undoubted drawback that a certain number of the cases suffer severely from cerebral symptoms as a result of the by-passing of the liver by nitrogenous material from the bowel. It has only rarely been tried as a method of treatment during the acute phase of bleeding. The only large series of such cases known to the writer is that of W. D. O'Sullivan and M. A. Payne (1956) who carried out an emergency porto-caval shunt on nine patients. Three patients died in a post-operative phase, one of unremitting haemorrhage. Of the six survivors, three had since died, two of homologous serum jaundice, but none of the survivors had bled again. Hepatic artery ligation has a very doubtful place in the treatment of portal hypertension. It has been used as an interval operation for acutely bleeding oesophageal varices, but W. A. Altmeier and his associates (1955) found recurrent bleeding in six out of eighteen cases in which it was tried. Two died of the operation, five more died within five and a half months and two died of recurrent bleeding. Their experience would suggest that there is no place for hepatic artery ligation in the treatment of bleeding oesophageal varices. REFERENCES ALTMEIER, W. A. (1955) Arch. Surg. (Chicago) 71, 571. BOEREMA, I. (1949) Arch. chir. neerl. 1, CRILE, G., Jr. (1953) Surg. Gynec. Obstet, 96, 573. LINTON, R. R. (1953) Gastroenterology, 24, 1. O'SULLIVAN, W. D., and PAYNE, M. A. (1956) Surg. Givuec. Obstet. 102, 668. TANNER, N. C. (1950) Proc. Roy. Soc. Med. 43, 147. (1951) Edinb. med. J. 58, (1954) (1) Trans. med. Soc. Lond. 70, 202. (1954) (2) Proc. Roy. Soc. Med. 47, 475. DONATIONS DURING THE PAST month the following generous donations'have been received: Restoration and Development Fund: 100 Raymond Russell. 20,000 Agnes Spencer Charitable Trust. 10,000 Israel and Rebecca Sieff Charitable Trust. General Fund: s. Od. G. W. Films, Ltd. 42