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of the follow-up should indicate the experience of thedifferent categories of patients, with the yearlysurvival-rates calculated by one of the well-knownstatistical methods.

It will be unfortunate if resection of the lung, ofwhose worth many competent workers are convinced, 1is allowed to evolve haphazardly under the influenceonly of bedside impressions and reasoning fromuncertain premises. The clinician does not lightlydecide to advise a more or less fit patient to accepteven a slight risk of dying from resection in orderto avoid the unknown risk of dying from his diseasemany years later. The difference of opinion aboutthe merits of resection in certain types of diseasewarrants a fully controlled clinical trial. A start

might be made by comparing, in patients withuncavitated tuberculous nodules, the results ofresection and those of long-continued antibacterialtreatment.

1. See Lancet, 1953, ii, 1118.

Annotations

"SECTIONAL MEETING"

THE American College of Surgeons was founded in1913 on the model of the Royal College of Surgeons ofEngland ; the first fellowship address was given by thepresident of the English college, and the great mace waspresented by the consultant surgeons of the British Armyafter the first world war as a symbol of the brotherhoodbetween the two nations. The first London meeting ofthe American college, which has been held this week,is therefore a memorable occasion, and it is fitting thatit should be the first major event in the newly finishedgreat hall of the Royal college.The territory of the United States is-so vast, and the

fellows of the American college are so numerous, thatscientific meetings are held in sections. This week’s

meeting, attended by about 450 American surgeons, hasbeen organised by the Americans themselves on the linesof a typical sectional meeting in their own country, andthe tempo-so very different from that of our own

surgical meetings-has emphasised the difference in thetasks the two colleges are called on to fulfil. The Royalcollege, although at one time directly concerned in

surgical education, became largely an examining bodyand only in recent years has turned its attention againto fostering the basic sciences and surgical research.The American college, on the other hand, confronted bya rapidly growing population and by universities withoutthe advantage of tradition, has had to direct its attentionto postgraduate education and to ethical problems. Inthis country, with its static population and long-estab-lished training centres, it is hard to understand thedifficulties inherent in rapid expansion ; but those whohave watched the great struggle of the American collegeto ensure that postgraduate training is carried out onlyat hospitals with proper scientific standards can appreciatethe immense service it has rendered to American surgery,and also to the hospitals themselves, which have beenobliged to improve. This point gained, the battle con-tinues with the insistence that only the highest ethical,standards shall prevail throughout the length and breadthof the country.The two colleges, although of necessity their approach

has been different, are striving for the same end-toprovide the best service for the patient that is humanlypossible. Close personal and professional bonds linkBritish and American surgeons, and we hope that ourvisitors have been well enough pleased to come again.

MAGNESIUM

IN the field of electrolyte physiology and pathologythere are definite signs of a shift in emphasis awayfrom the electrostatic and osmotic effects of electrolytes,and towards their interactions with organic metabolism.Interest is being shown not only in the decisive effectof aerobiosis in stabilising the osmolarity and electrolytecomposition of cells 1 2 but also in the effects of electro-lyte distortion on the activity of enzymes. For example,experimental potassium deficiency was shown to impaircarbohydrate utilisation,3 and it has been suggested thatthe " insulin-resistant diabetes " induced by cortisonemay be related to the hormone-induced potassiumdepletion.4 Potassium depletion is also known to impairprotein synthesis, even when the dietary intake of

protein itself is adequate.5 Since magnesium is, nextto potassium, the predominant cation of intracellularfluid, and since it is a necessary constituent of variousenzyme systems,6 much of the interest now shown inpotassium may soon be extended to magnesium. Studiesare at present handicapped by the lack of a usable

radio-isotope of magnesium, and by there being nomethod of estimation comparable in ease and accuracyto that of flame photometry for sodium and potassium.

There are a few indications from clinical reportsthat depletion or excess of magnesium may be important. 7The effects of induced magnesium depletion on musclecomposition have been investigated in rats 8; andin cattle,9 rats,10 and ducklings,11 such depletion hasbeen found to cause tremors and convulsions. Itseems that in man magnesium depletion may developin circumstances known to be associated with potassiumdepletion. For example, it has been detected after

operation in patients whose fluid balance was beingmaintained by parenteral fluids not containing mag-nesium 12 ; magnesium excretion continues in the urineeven at low serum levels of magnesium. 7 Magnesiumdepletion has also been found in patients with diabeticcoma,13 and in patients with congestive heart-failuretreated with mercurial diuretics and with cation-exchangeresins. 7 All these associations would indicate a renalloss of magnesium ; and comparison with potassiumsuggests that the effects of deficient food intake and ofabnormal losses of gastro-intestinal fluid should beexplored in relation to magnesium. A recent reportsuggests that magnesium deficiency may be responsiblefor the tremulous moiety of delirium tremens ; low

serum-magnesium levels were observed, and treatmentwith intramuscular magnesium sulphate improved thetremor, assessed by handwriting tests.14 In this reportemphasis is laid on the importance of alcohol, well

recognised in other contexts, in preventing an adequateintake of food, which is either unwanted or cannot bepaid for. -

Although tetany associated with low levels of serum-magnesium has been recognised in animals 10 and in

man,15 16 this finding has attracted little clinical atten-1. Robinson, J. R. Proc. roy. Soc. B. 1950, 137, 378 ; Biol. Rev.

1953, 28, 158.2. Davies, R. E., Krebs, H. A. Biochemical Society Symposia,

no. 8. Cambridge, 1952 ; p. 77.3. Gardner, L. I., Talbot, N. I., Cook, C. D., Berman, H., Uribe, C.

J. Lab. clin. Med. 1950, 35, 592.4. Kinsell, L. W., Balch, H. E., Michaels, G. D. Metabolism,

1953, 2, 421.5. Cannon, P. R., Frazier, L. E., Hughes, R. H. Ibid, 1952, 1, 49.6. Lehninger, A. L. Physiol. Rev. 1950, 30, 393.7. Martin, H. E., Mehl, J., Wertman, M. Med. Clin. N. Amer.

1952, 36, 1157.8. Cotlove, E., Holliday, M. A., Schwartz, R., Wallace, W. M.,

Amer. J. Physiol. 1951, 167, 665.9. Sjollema, D. Nutr. Abst. Rev. 1932, 1, 621.

10. Kruse, H. D., Orent, E. R., McCollum, E. V. J. biol. Chem.1932, 96, 519.

11. Van Reen, R., Pearson, P. B. J. Nutr. 1953, 51, 191.12. Martin, H. E., Edmondson, H., Homann, R., Berne, C. J.

Amer. J. Med. 1950, 8, 529.13. Martin, H. E., Wertman, M. J. clin. Invest. 1947, 26, 217.14. Flink, E. B., Sturzman, F. L., Anderson, A. R., Konig, T.,

Fraser, R. J. Lab. clin. Med. 1954, 43, 169.15. Hirschfelder, A. D. J. Amer. med. Ass. 1934, 102, 1138.16. Miller J. I. Amer. J. Dis. Child. 1944, 67, 117.

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tion, largely because many patients with comparablylow levels of serum-magnesium are free of symptoms.The analogy with potassium is again tempting, andclearly we shall need to learn much more about the rôleof magnesium within the cell before we can explain theoccasional occurrence and fre,quent absence of tetanyin patients with a low serum-magnesium. The greaterpart of the cell magnesium is probably undissociated,being " bound " to protein and phosphate anions.17 ISLow serum levels of ionic calcium are much more

constantly associated with tetany ; and these twodivalent cations probably exert different effects on

muscle activity, since one type of muscle adenosine-

triphosphatase has been found to be activated by calciumions and inhibited by magnesium ions.19 These are deepwaters, and for -the present clinicians may be contentto remember the possibility of magnesium tetany.High serum-magnesium values have been observedin kidney disease, and may contribute to the drowsinesswhich is sometimes a merciful feature of terminal renalfailure. Warnings have been issued against precipitatingterminal coma by magnesium sulphate purgation 20 ;and this should certainly be avoided in the reversiblesyndrome of acute tubular necrosis. A high level ofprotein-bound serum-magnesium has been reportedin hyperthyroidism,21 but careful studies by Cope andWolff 22 did not substantiate this claim.Thus there is more of promise than of fulfilment in

the study of magnesium in relation to disease ; butthe same could have been said of sodium twenty yearsago, or of potassium ten years ago.

17. Conway, E. J., Cruess-Callaghan, G. Biochem. J. 1937, 31,828.

18. Tabor, H., Hastings, A. B. J. biol. Chem. 1943, 148, 627.19. Kielley, W. W., Meyerhof, O. Ibid, 1948, 174, 387.20. Haury, V. G., Cantarow, A. J. Lab. clin. Med. 1942, 27, 617.21. Soffer, L. J., Cohn, C., Grossman, E. B., Jacobs, M., Sobotka, H.

J. clin. Invest. 1941, 20, 429.22. Cope. C. L., Wolff, B. Biochem. J. 1942, 36 413.23. Almoner. April, 1954, p. 3.

MORE SELF-HELP

THE early social workers had little to offer the needyexcept good advice. We now seem to have reached theopposite pole : there are plenty of services to be had,but no-one seems to be responsible for explaining tothe needy what these are or how to get them. In viewof the large variety of social workers who now haveaccess to the homes of the nation, this is rather remark-able. Nevertheless, as Prof. Leslie Banks 23 told theannual general meeting of the Institute of Almoners,recent surveys have shown that many people, and

especially old people, in villages and towns, are unawarethat the district nursing service is free, or that they canhave the assistance of a home help when necessary.Moreover, they are often completely defeated when theyare asked to fill in a form or write a letter in answer toan official inquiry. We need, he thinks, advisorycentres capable of helping such people in a friendlyunofficial manner.The kinds of help we now provide are financial and

practical ; and he is anxious to see that these are givenin the right way, and to the right people. Too much

help saps initiative ; and besides, we cannot afford to

supply it. "A small and self-reliant family," he says,"

given a healthy environment and a reasonable standardof education, should need help only in times of crisis."If they have a good family doctor, district nurse, andmidwife, and a centre to which they can go-and heemphasised " go "-for information, do they need

anything more ? And will routine visiting by a troopof social workers do more than weaken their self-confidence and self-respect ? On the other hand, thereare some 5-12% of families in any area who have preciouslittle self-confidence and self-respect to keep them

going, and these he thinks, will continue to need intensive

care. It is questionable, however, whether they infact need the combined care of the health visitor, housinginspector, sanitary inspector, N.S.P.C.C. inspector,probation officer, school welfare officer, boarding-outofficer, children’s officer, moral welfare worker, and theofficers of the National Assistance Board. ProfessorBanks thinks our society is now so complex that wecould not substitute one all-round officer for this littlearmy ; but we might reduce the confusion, he suggests,by ensuring at least that all these workers have a commonbasic training. It is perhaps worth recalling that thoughAmerican society is at least as complex as ours, mostof the functions which here are distributed among somany are undertaken in the United States by a soJitaryworker, the public-health nurse. At present our NationalHealth Service is employing some 400,000 women;but during the next ten years the number of women inthe country aged 18-30 is going to decline by over200,000 ; and every year (until 1960) there will be100,000 fewer girls reaching the age of 18 than therewere in 1930. So the field of recruitment is going to besmaller, and to go on diminishing. This means that unlesswe manage to be more economical in their use, everysocial worker will have a larger case-load-i.e., she willhave to do less for more people.

This is perhaps less serious than it sounds. Dr. H. M. C.Macaulay 24 points out that a welfare saturation pointis not beyond the bounds of possibility. He does notthink that we have reached it, by any means, but hedoes suggest that if, in the second half of the century,public-health education is as successful as it has beenin the first half, the proportion of feckless families in thecommunity may dwindle below their present 7-12% ;and that will mean a considerable lightening of the load.Moreover, as Professor Banks notes, we have shakenourselves free, now, of many of the social and medicalill effects of the Industrial Revolution, and have addednearly thirty years to the expectation of life at birth.Family size is small, the standard of health is high,and the ways of education and instruction-for thoseable to profit by them-are many. Social workersshould now be able to look on many of those they helpnot as patients, but as clients seeking advice. A popula-tion such as we used to have, with a high proportion ofchildren and adolescents, and many illiterates, neededmuch supervision and inspection ; but our presentpopulation-older, more mature-should need little

beyond security and a healthy environment (in which heincludes good housing). The task of the social worker isstill to " advise, assist and befriend " ; but for our

medicosocial services, whether statutory or voluntary.the task is rather to decide which people stand in needof advice, assistance, and friendship, and in what mannerit should be given.

24. Ibid, p. 1.25. Hogness, J. R., Burnell, J. M. Arch. intern. Med. 1954, 93, 355.

MEDULLARY CYSTS OF THE KIDNEY

AN unusual variety of congenital cystic disease of thekidney has lately been described by Hogness andBurnell.25 The cysts are confined to the medulla; andthe cortex undergoes atrophic changes from back pressureor from interference with the vascular tree. Clinically,the patients resemble those with the Rose-Bradfordkidney in that they develop an insidious uraemia withouthypertension ; and a further strong point of resemblanceis the occurrence of osteitis fibrosa in 3 of these cases,with proved hyperplasia of the parathyroid glands in 2.No excretion pyelograms were carried out, and the

retrograde pyelograms gave no diagnostic picture.This cannot be a common condition, for only 1 case

could be added from the literature to the authors’ 4. Itis probably a developmental defect, since associatedcongenital abnormalities were found in 2 cases, and there