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which regeneration can proceed. The aim of temporaryhepatic support is to prolong survival to a stage whereregenerated hepatocytes can take over or possibly, incases with no surviving hepatocytes, until a donor livercan be transplanted. Unfortunately, no system is yetable to provide such excellent support. The best that hasbeen achieved by the entirely artificial approach is sur-vival figures of about 30% with charcoal haemoperfu-sion 7 or hxmodialysis over polyacrylonitrile mem-branes.8,9

Experimentally the most effective support, as mightbe expected, comes from the provision of a new liver asa temporary auxiliary organ transplant. 10. 11 Clinical ex-perience is more limited but one patient with subacutehepatic necrosis recovered quickly from grade-IV comaafter orthotopic transplantation.12 But these formidablesurgical procedures have many associated problems, ofwhich one of the most intractable is the urgent require-ment for a suitable donor organ. Rejection has neverbeen a major difficulty. The most common cause of graftfailure is breakdown of the biliary anastomosis, thoughearly results with Calne’s new technique, in which thedonor gallbladder is used as a well vascularised conduit,are encouraging.13 These complex biliary and vascularanastomoses are necessary only because the wholeframework of the liver has been used as a vehicle for

transplanting hepatocytes, and since in fulminant hepa-tic failure the framework and associated vessels andducts are nearly intact a more logical approach would beto transplant hepatocytes alone. A report by Sutherlandet al.14 illustrates the potential importance of hepatocytetransplantation in the search for effective temporaryhepatic support. Liver necrosis was induced in rats byadministration of dimethylnitrosamine in a dose whichallowed long-term survival, in control groups, of 6-17%.Liver cells from animals of the same inbred strain were

prepared by pressing small pieces of liver through wirescreens and were then injected into either the portal veinor the peritoneal cavity of rats which had been givendimethylnitrosamine 24 hours earlier. The percentagessurviving for more than sixty days were 71 after portal-vein injection of the liver cells and 63 after intraperi-toneal injection. The changes in survival are dramaticbut the mechanism is not yet clear. Hepatocytes seemedto survive the transplant procedure when injected intothe portal vein, for histological examination of the liverin the recipients showed nodules of liver cells in portalvenules, sinusoids, and central veins for up to thirtydays after injection. However, after intraperitoneal in-jection the transplanted hepatocytes could not be defi-nitely identified, small nodules which did appear on ser-osal surfaces at 5 days consisting primarily of

macrophages surrounding a necrotic centre. Experi-ments with cells from other organs will be required toestablish the specificity of liver-cell transplantation; andeven if the effect is organ-specific the cell type respon-6. Gazzard, B. G., Portmann, B., Murray-Lyon, I. M., Williams, R. Q. Jl Med.

1975, 44, 615.7. Gazzard, B. G., et al. Lancet, 1974, i, 1301.8. Opolon, P. Proceedings of the Second International Symposium for Artificial

Organs, Tokyo, 1977 (in the press).9. Silk, D. B. A., et al. Lancet, 1977, ii, 1.

10. Kuster, G. G. R., Woods, J. E. Ann. Surg. 1972, 176, 732.11. Diaz, A., Ricco, J. B., Franco, D. Archs Surg, 1977, 112, 74.12. Williams, R. Br. med. J. 1970, i, 585.13. Calne, R. Y., Williams, R. ibid. 1977, i, 471.14. Sutherland, D. E. R., Numata, M., Matas, A. J., Simmons, R. L., Najarian,

J. S. Surgery, 1977, 82, 124.

sible for the increased survival will need to be evaluatedcarefully. The severity of liver-cell damage after admin-istration of galactosamine in rats is greatly affected bymanipulation of reticuloendothelial-cell function, ISprobably because of the ability of Kupffer cells to pre-vent the systemic endotoxxmia which accompanies theliver injury and may be perpetuating the liver-cell

damage.16 Thus, it is possible that the Kupffer cellsrather than the hepatocytes in the liver-cell transplantare playing an important part in modifying survival inthe dimethylnitrosamine-treated animals.Many obstacles have to be surmounted before we can

think of applying this technique clinically. The experi-ments so far have used hepatocytes from inbred strains,and although initial studies in rats across a weak histo-compatibility barrier are encouraging,14 allogeneic cellsmust now be tested in larger outbred-animal models,both with and without immunosuppression. The urgentrequirement for donor tissue will continue to present dif-ficulties. Long-term hepatocyte cultures are notoriouslyhard to set up and the surviving cells tend to undergoprogressive dedifferentiation. Xenogeneic donor cells area possible alternative, but it is doubtful with suchpowerful histocompatibility differences whether the

transplanted hepatocytes would survive long enough tomake much difference to liver function.

GENERAL-PRACTICE TRAINING, EXETER STYLE

THERE is seldom much difficulty for medical studentsin the transition from school to the preclinical course.The critical break comes at the beginning of clinicaltraining when they find themselves suddenly in closecontact with serious illness, pain, fear, and death in thewards of their teaching hospital. It is usually a dauntingexperience, although familiarity with the clinical scenesoon dulls the memory of that first impact. The students,looking for support from the medical staff, adopt staffvalues and attitudes in order to cope in the intenseclosed world of the teaching hospital. These attitudes,which often implicitly or explicitly denigrate medicineoutside hospitals, are deeply imprinted throughout clini-cal training. It is an admirable training for future con-sultants and, until recently, it was assumed to be a per-fectly satisfactory training for general practitioners.Inside the hospitals, general practice was often seensimply as the practice of the easy and duller parts of themain specialties under less favourable conditions-nomore and no less. "Interesting", or "real" medicine was,by definition, in the hospital: the rest outside.

Against this background, the need for formal trainingin general practice became obvious, and the past decadehas seen an extraordinarily rapid growth of post-graduate training for general practice. What direction isthis training taking today? This question is raised by thepublication of an account of the Exeter system of train-ing. The Exeter programme has two main facets. In thewords of Pereira Gray,’ "Patient-centred medicine andlearner-centred education ... represent two great

15. Grün, M., Liehr, H., Grün, W., Rasenack, U., Brunswig, D. Acta hepatogas-troenterol. 1974, 21, 5.

16. Grün, M., Liehr, H., Rasenack, U. ibid. 1977, 24, 64.1. A System of Training for General Practice By D. J. PEREIRA GRAY. Occa-

sional paper No. 4. Journal of the Royal College of General Practitioners,September 1977.

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streams of thought flowing together to form a river ofpostgraduate training for general practice ... which willeventually burst the banks of general practice to

overflow and influence the whole of medical education."Educational theory plays a large part in the trainingprogramme, and familiarity is needed with the languageof educational paradigms, group work, modelling andreinforcement, as well as those old friends, aims andobjectives. Educational theory is regarded as a behav-ioural science from which a number of controversialassumptions emerge; for instance, "... learning frompeers is inherently better than learning from superiors;the effect of authority is eliminated..." and "the doctor-patient relationship in general practice is directly anal-ogous to the trainer/trainee relationship".

In Exeter, development of "correct" general-practi-tioner attitudes is considered of prime importance. Anattitude inventory has been devised which is used torecord the number of general-practitioner attitudes

gained and consultant attitudes lost by the trainee atintervals throughout his training. This, and other

aspects of the essay, reveal what is perhaps the most dis-turbing tendency of this system of training-a tendencyto reject hospital attitudes as divorced from, and inap-propriate to, general practice. Pereira Gray recalls twoexamples of crassly insensitive behaviour by hospitalconsultants as if they were characteristic of all consul-tants, and records his own "iron determination to findother settings in which medicine could be practised". Agreat deal of the Exeter programme is original, provoca-tive, stimulating, and thoughtful. No one would quarrelwith the emphasis placed on the importance of sensiti-vity, patient-centred medicine, self-awareness, and thepreservation of the patient’s dignity. They should be fea-tures of training in all branches of medicine. Hospitalmedicine and general practice are totally dependent oneach other, and the crying need at the moment is for thedevelopment of mutual understanding and respectthrough closer integration of training at undergraduateand postgraduate levels. General practice is a branch ofmedicine that is potentially as difficult, as interesting,and as demanding intellectually as any other, but it can-not work in total isolation, nor does it need to over-reactagainst the paternalistic authoritarian attitudes of theteaching hospitals that have dominated medical trainingin the past. The twin disciplines of general practice andhospital medicine are not only interdependent, they havea great deal to learn from each other.

LACTICACIDOSIS IN ALCOHOLIC BERI-BERI

THE mortality from non-phenformin-associated lac-ticacidosis is about 80%; in phenformin-associated lac-ticacidosis the mortality is just under 50% if treatmentis given before the onset of shock, and about 65% ifshock is present by the time treatment is started. 1

Majoor2 now records an unusual case of lacticacidosiswhich yielded promptly to treatment with thiamine.The patient was one of four alcoholics with cardiac

beri-beri: blood-pressure was low and pulse-pressurehigh; he was dyspnoeic without rales; cardiac output washigh despite peripheral cyanosis and cold extremities;and there was little oedema. He was severely acidotic,1. Lancet, 1973, ii, 27.2. Majoor, C. L. H. Jl R. Coll. Physns, 1978, 12, 143.

with a serum-lactate of 24.5 mmol/l. With bicarbonateinfusion, his pH rose but so did venous pressure. Butafter three days of thiamine injections he recovered.

Majoor unearthed two reported cases with very simi-lar circulatory and metabolic features. The acute fulmi-nating form of cardiac beri-beri is known to the

Japanese as shoshin (sho=acute damage; shin=heart).Typically the patient, like Majoor’s, has rapid respira-tion but clear lungs, cold cyanotic face and limbs, dis-tended jugular veins, severe abdominal pain, and an ex-tremely tender and swollen liver. Patients with shoshintend to die rapidly, and metabolic acidosis could well bethe reason. Acidosis in alcohol-associated cardiac beri-beri may have a double, or even triple, origin. Both alco-hol and deficiency of thiamine tend to divert thecitric-acid cycle towards lactate production; and

p-hydroxybutyricacidosis has been recorded in malnour-ished alcoholics. With thiamine injections and alcoholwithdrawal, the outlook in this rare condition shouldnot be bad.

EXPORTS AND THE N.H.S.

THE bid by the National Enterprise Board for a com-pany with a subsidiary entrenched in the private sectorof health care has not strayed far outside the financialpages of the Press, where controversy has centred onwhether the bid is good for shareholders. The subsid-iary, the Allied Medical Group, has a 250 million con-tract to manage two hospitals in Riyadh; and "manage"means staff as well as equip. The scope of the recruit-ment needed to meet the staffing commitment in the con-tract can be seen from our advertising pages this week(London edition). Generous though the tax-free salariesand fringe benefits seem to be they may not be enoughto tempt established specialists in, say, North America;and there are other reasons for supposing that the needto recruit medical staff could represent a raid in breadth,if not in depth, on the medical manpower of the N.H.S.The contract is the product of an agreement between thegovernments of the U.K. and Saudi Arabia. One out-come of Mrs Barbara Castle’s sales tour of the MiddleEast two years ago was discussions with health authori-ties with a view to achieving cooperation with anyexport drive, and it was recognised then that U.K.equipment manufacturers would have an advantage ifthere were a link with the N.H.S., whose workers aremuch respected in the Middle East. To The Times (Jan.10) the association is essential: "If Allied is to stay in thebig league internationally it will be a considerable

advantage to be controlled by a government agency andthereby to be linked directly to the National Health Ser-vice." The Government recognises the ambivalence ingiving all the appearances of opposition to private prac-tice while fostering an arrangement that is nothing ifnot entrepreneurial; hence the announcement thatAllied’s private medicine interests in the U.K. would besold. It also, through the Department of Health, believesthat for the moment the drain on the N.H.S. will not be

significant, but this is not the first contract of this sortto be signed and it will probably not be the last, andstaffing requirements do not stop at doctors. Formerly,private enterprise baked the export cake with the N.H.S.providing the icing: from now on there may be only onecook.