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plete pair 2. In some metaphases the configuration of doublering was so clear that it looked as if there was only one centro-mere. Fig. 1 shows four rings in four different mitoses. Fig. 2shows chromosome pairing in one of the mitoses. Because ofthe high frequency of the abnormality (90% of metaphaseplates) we think we are dealing here with a self-perpetuatingchromosome.

We believe that this is the first time such findings havebeen reported in this disease, although ring chromosomeshave been found in other disorders-e.g., in neoplasms,2after radiation therapy,3 in two cases of rare congenitalanomalies,4 and, latterly, in acute leukaemia, s

FRANCISCO DI GRADOFERNANDO TEIXEIRA MENDESERNESTO SCHROEDER.

Hospital das Clinicas,Faculty of Medicine,

University of São Paulo,Brazil.

INTENSIVE-CARE UNITS FOR PATIENTS WITH

ACUTE MYOCARDIAL INFARCTION

E. D. ACHESON.Oxford Record Linkage Study,

Oxford.

SIR,-Dr. Shillingford and Dr. Thomas (Nov. 21) withcommendable caution point out that it is too early to assessthe benefits or otherwise of the special measures taken atHammersmith Hospital. When the time for assessmentarrives they will require a group of similar but untreatedcases for comparison.From their description of its size, the unit seems too

small to accommodate more than a few of the patientsadmitted to the hospital with acute myocardial infarction.This implies that the cases treated in the intensive-careunit must be selected. May I suggest that this provides anideal opportunity for a formal controlled trial of the newtreatment based on the principle of randomisation?Judging by previous experience, the trial should beinstituted soon while it still cannot easily be regarded asunethical either to exclude (or admit) patients to it. Inview of the nature of the problem, an answer could beobtained quickly.

CLOSED-CHEST CARDIAC MASSAGE

J. CHARLES SHEEDENIS H. THOMPSON.

Central Hospital,Kumalo,Bulawayo,

Southern Rhodesia.

SIR,-In view of the scepticism expressed by Dr. AlanGilston (Oct. 17) of the value of internal cardiac massageafter external massage has failed, we should like to drawattention to our report 6 of a patient resuscitated in thesecircumstances. Effective beating had failed to returnafter thirteen minutes of external cardiac massage; internalcardiac massage was then maintained for almost one and ahalf hours before effective defibrillation was established.

Incidentally, mouth-to-mouth respiration was not utilisedat any stage, which makes us feel that this measure may be

supererogatory, and that adequate ventilation can be main-tained by rhythmic compression of the closed chest alone.Intubation and artificial oxygenation was only instituted at themoment of thoracotomy, and it may well be that mouth-to-mouth respiration merely adds the complication and fuss of anadditional person working on the patient’s body in what is

already a desperately difficult situation.We are happy to add that, almost three years later, our

patient, beyond a thoracotomy scar and electrocardiographicevidence of former infarction, presents no physical or mentalstigmata of his ordeal and lives a completely normal life.

2. Levan, A. Hereditas, 1956, 42, 366.3. Tough, I. M., Buckton, K. E., Baikie, A. G., Court-Brown, W. M.

Lancet, 1960, ii, 849.4. Wang, H. C., Melnyk, J., McDonald, L. T., Ushida, I. A. Nature,

Lond. 1962, 195, 733.5. Sandberg, A. A., Ishihara, T., Crosswhite, L. H., Hauschka, T. S.

Cancer Res. 1962, 22, 748.6. Brit. med. J. 1963, i, 1135.

INTRACRANIAL HYPERTENSION AND STEROIDS

MICHAEL KELLY.

Institute of Rheumatology,410, Albert Street,East Melbourne,

Victoria, Australia.

SIR,-I hope that your leading article (Nov. 14) willdiscourage the neurologists who favour steroid treatmentof a non-fatal disease such as herpes zoster. From thebeginning the most dangerous steroid effects have beenneural, and convulsions have been recognised as a steroidtoxic effect-particularly of steroid withdrawal. 2 3

GALLSTONES AND GASTRECTOMY

GEORG RIESENFELD.Rothschild Hospital,

Haifa, Israel.

SiR,—The proportion of patients with biliary-tractdisease following gastric surgery reported by Dr. Griffithsand Mr. Holmes (Oct. 10) is impressive. It is doubtful,however, whether their conclusions apply generally.

In a personal series of 784 patients (640 women and 144 men)who underwent surgery for disease of the gallbladder and/orthe common bileduct, over the past ten years, there was only1 who had previously undergone surgery for duodenal ulcer.6 patients in this series were operated on for simultaneousduodenal ulcer and biliary disease.

It is well known that many stones in the gallbladder, especiallysmall ones, are impossible to demonstrate clinically, and canbe discovered only on opening the gallbladder-a procedurecertainly not performed during routine gastric operations.

Either some of the gallbladders were harbouring stonesat the time of the first operation, or there must have beensome other, unrecognised factor in the series reported byDr. Griffiths and Mr. Holmes.

SiR,—In your editorial (Nov. 21) you indicate that theoccurrence of gallstones in post-gastrectomy patients is anindictment of this operation when it involves a gastro-jejunal anastomosis.

Dr. Griffiths and Mr. Holmes (Oct. 10) have rightly pointedout that after a gastroenterostomy or gastrectomy of the Polyatype, no food enters the duodenum. It is likely, therefore, thatcholecystokinin production, and the associated evacuation ofthe gallbladder, is interfered with after such operations. Youend your editorial with the suggestion that " a late study ofpost-vagotomy cases with pyloroplasty or antrectomy ratherthan those with the diversion caused by gastroenterostomymight indicate which of the two mechanisms is at greaterrisk."A partial gastrectomy, which is completed with a retrocolic

end-to-side, no-loop anastomosis between the gastric remnantand the fourth part of duodenum,4 is not followed by diversionof gastric chyme from the second and third parts of theduodenum. Capper and Butler in barium studies, have shownthat after this type of operation a large part of the chyme fromthe stoma passes to and fro in the proximal duodenum. Thisoperation should permit adequate secretion of cholecystokininand proper emptying of the gallbladder. The gallbladder willof course dilate whether the primary operation has been agastrectomy or a vagotomy, but emptying of the gallbladdershould not be delayed in a gastrectomy in which the anastomosisis made to the fourth part of the duodenum. It is this inter-ference with gallbladder emptying which is probably responsiblefor biliary stasis, stone formation, and cholecystitis after thePolya gastrectomy and the usual type of gastroenterostomy.Any study of this type of cholecystitis and biliary-tract diseaseshould include a follow-up of this type of gastrectomy.

In carrying out this operation I have found that the fourthand third part of the duodenum can be mobilised until the right1. Elliott, F. J. Amer. med. Ass. 1964, 189, 649; Lancet, Sept. 19, 1964,

p. 610.2. Stephen, E. H. M., Noad, K. B. Med. J. Aust. 1951, ii, 333.3. Gaisford, W. J. Pediat. 1960, 56, 219; Brit. med. J. 1962, ii, 1517.4. Orr, I. Ann. R. Coll. Surg. Engl. 1964, 34, 3.5. Capper, W. M., Butler, F. J. Brit. med. J. 1964, i, 1708.