First gastrectomy 1964

1044 18 April 1964 Correspondence

no knowledge as to whether it is a widelyrecognized occurrence.

Last year I was treating an elderly ladywho suffered from congestive heart failureand severe osteoarthritis of her knees. Oraldiuretics were insufficient to control the ex-tensive oedema of her legs and it seemeddesirable to reinforce this with weekly injec-tion of " neptal " (o-(2-hydroxy-3-hydroxy-mercuripropylcarbomyl) phenoxyacetic acidand theophylline). This produced a satisfac-tory diminution in the oedema, but it becamevery evident that on each occasion it wasaccompanied by exacerbation of the pain inher knees, which improved as the oedema re-formed in the course of the next few days.Your article suggests that the lubrication

of joints depends on the viscosity of the syn-ovial fluid rather than on the quantity, butthe inference I drew from my patient wasthat the bone surfaces were being kept separ-ated by an increased volume of intra-articularfluid, as part of the general oedema of theleg, and that the diuretic produced a relativeintra-articular dehydration and consequentfriction. At all events the patient was grate-ful when I treated her oedema less diligently.-I am, etc.,Tunbridge Wells, A. CAMERON.

Kent.

SIR,-Your leading article " Lubricationof Joints " (15 February, p. 384) containsa good account of the paradox which resultswhen one tries to account for joint behaviourin terms of classical engineering. However,its precis of weeping lubrication is incorrect.The article states, " On this theory the

articular cartilage exudes lubricant in advanceof the point of pressure, encouraging hydro-dynamic lubrication at the point of contact."While the squeezing out of liquid ahead ofthe area of contact undoubtedly occurs tosome degree, it can only be of the minutestimportance in lubrication, because this regionis already wet.What is important is that the spongy struc-

ture of cartilage automatically provideshydrostatic (not hydrodynamic) lubrication.This is because the sponge skeleton is veryweak in compression. Were the liquid con-tained within the cartilage free to movethrough the sponge skeleton without viscousresistance it would be expelled immediatelyupon application of load, leaving the cartilagesquashed down solid at about half its originalthickness. In fact the pore size is so small,and the viscous resistance correspondingly solarge, that expulsion of the liquid takesseveral hours.

During this period the load is carriedpartly by hydrostatic pressure in the liquidand partly by elastic forces in the spongeskeleton. To an animal it is the first fewminutes which matter, and then the load iscarried almost entirely (and almost friction-lessly) by the liquid because the skeleton willbe but slightly deformed.You also state, presumably as a weakness

in the case for weeping lubrication, that it isnot established whether the hyaluronic acid ofsynovial fluid is found within articular carti-lage. It is likely that it will not be. Thepores of cartilage seem too small to admit thelarge polymer molecules. The liquid incartilage would thus be an ultrafiltrate ofsynovial fluid, but it would be liquid nonethe less and perfectly able to carry load byhydrostatic pressure.

For the explanation of how cartilagemanages, with its feeble sponge skeleton, torecover the fluid which is squeezed out underload, may I refer your readers to an articlein the New Scientist ?P-I am, etc.,

C. W. MCCUTCHEN.Laboratory of Experimental Pathology,

National Institute of Arthritis andMetabolic Diseases,

Bethesda 14,Maryland, U.S.A.

REFERENCEMcCutchen, C. W., New Scientist, 1962, 15, 412.

SIR,-In a letter which you published on28 March (p. 835) Mr. D. B. Welbournremarks that he has never seen the " squish"bearing discussed in engineering literature.May I refer him to H. W. Swift,," Fluctu-

ating Loads in Sleeve Bearings " (7. Inst. civilEngineers, February 1937). This paper givesa fairly extensive theory for a bearing pinmoving about in the clearance space of anoil-filled bearing bush, both without and withrotation of the pin.-I am, etc.,

Bedford. A. C. HUTCHINSON.

Latex Fixation in Liver Disease

SIR,-We were interested in your leadingarticle (28 March, p. 794) because we havebeen trying to assess the value of the R.A.latex test in diagnosis of liver disease andespecially jaundice. So far we have testedthe serum from 71 patients, and the resultsare as follows:

Total Positive Negative

Cholecystitis (withoutjaundice) .. .. 15 0 15

Extrahepatic obstructivejaundice .. .. 17 1 16

Intrahepatic obstructivejaundice .. .. 18 7 11

Portal cirrhosis .. .. 21 15 6

As yet we have found no consistent patternof reaction in the conditions which make upthe intrahepatic group, such as infectivehepatitis, drug jaundice, and chronic intra-hepatic obstructive jaundice (" primarybiliary cirrhosis "), and the high proportionof negative results is disappointing. On theother hand a positive test in obstructivejaundice almost certainly excludes an extra-hepatic cause. We can also confirm thestrong reactions that occur in patients withportal cirrhosis who show signs of activedisease such as jaundice, ascites, and hepaticfailure.

Like Dr. I. A. D. Bouchier and his col-leagues (7 March, p. 592), whose article yourleader writer appears to have ignored, wehave excluded weakly positive reactions. Butwe have been struck by their frequency in thisgroup of patients, and it may be that quanti-tative methods should be employed to estab-lish the significance of R.A. latex fixation inliver disease.-We are, etc.,

Dudley Road Hospital, P. R. BUTLER.Birmingham 18. A. PATON.

*** We regret omitting reference to thepaper by I. A. D. Bouchier et al.-ED.,B.M.7.

Treatment of Dumping Syndrome

SIR,-In answer to your correspondentDr. Steven S. Smith (28 March, p. 835)about the lack of a " central bureau of in-formation " on syndromes after gastrectomy,there are, of course, innumerable articles onpost-gastrectomy syndromes listed in theCumulative Index Medicus, Current List ofMedical Literature, and the Index Medicusfairly soon after they appear, which he canrefer to if he has access to these tomes. Ifnot, then reviews appear from time to timeon this as on so many subjects, summarizingmedical information to date.The Birmingham School of Medicine has

been very much concerned with these syn-dromes over the past 15 years and two mono-graphs have recently been published whichshould be of help. He will find reviews ofhis particular problem in Dr. C. F. Hawkins'sbook Diseases of the Alimentary Tract (chap-ter V, " gastric operations and their meta-bolic sequelae ") (London, Heinemann, 1963)and in Partial Gastrectomy (Stammers andWilliams) (London, Butterworths, 1963). Theproblem of the use of antibacterial agents ishere specifically referred to in chapter 10," Under-nutrition, malnutrition, and mal-absorption after gastrectomy."-I am, etc.,

Queen Elizabeth Hospital. J. M. FRENCH.Birmingham 15.

When was the First Gastrectomy ?

SIR,-In his review (7 March, p. 623) ofGastric Surgery. Errors, Safeguards andManagement of Malfunction Syndromes, byMoses E. Steinberg (1963), Sir CharlesIllingworth writes, " The first part of thisbook reviews at some length the history ofgastric surgery, from the first gastro-jejunostomy performed by Wolfler in 1881and the first gastrectomy by Rydygier in1882. . . ."But according to Aird' the Billroth I

operation was the first successful gastrectomy.It was first successfully performed by Billrothin 1881, but had previously been unsuccess-fully attempted by Pean. Farquharson' alsogives 1881 as the year of Billroth's firstoperation.

Maingot' records, " Pean (Gaz. Hop. Paris,1879, 52, 473) at the Hospital of Saint Louisperformed the first recorded pyloric resectionfor carcinoma on a human. His patient diedon the fifth post-operative day. Rydygier(Arch. klin. Chir., 1881, 26, 731), on 16November 1880, performed the secondpyloric resection on a human for carcinomaof the pylorus. He re-established continuityby gastroduodenal anastomosis with a seriesof interrupted silk sutures. This patientcollapsed and died some 12 hours followingthe operation.

" The first successful resection for cancer ofthe stomach was accomplished by Billroth in1881 (Wein. med. Wschr., 1881, 31, 161).Rydygier (1881) stated that Billroth per-formed the third pylorectomy with gastro-duodenostomy for an obstructing carcinomaof the pylorus in the human. Billroth hadno knowledge of Rydygier's case when hesuccessfully carried out this operation on29 January 1881. The patient was a womanaged 43 and the pyloric tumour was mobileand lent itself readily to resection. She un-

BRITISH 104518 April 1964 Correspondence MEDICAL JOURNAL 14

fortunately died four months after theoperation from liver metastases."Which is correct ?-I am, etc.,North Ormesby Hospital, S. D. SARKAR.

Middlesbrough.

REFERENCESAird, I., A Companion in Surgical Studies, 2nd

ed., 1957, p. 772. Livingstone, Edinburgh.2 Farquharson, E. L., Textbook of Operative Sur-

gery, 2nd ed., 1962, p. 526. Livingstone,Edinburgh.

3Maingot, R., Abdominal Operations, 4th ed.,1961, p. 203. Appleton Century Crofts, NewYork.

Bedside HazardSIR,-Your number of 1 February has

only just come to my attention, and I hopeit is not too late to comment on Dr. P. M.Corkey's interesting letter on " BedsideHazard " (p. 311). He suggests that theshattering of a tumbler beside the bed wascaused by the sound waves emitted by a smalltransistor radio, the volume of which wasturned right down. If the volume wasturned down, the energy of any sound waveswould have been correspondingly reduced,and it is difficult to believe that it could havebeen sufficient to shatter the glass.My scepticism is heightened by the fact

that a colleague of mine had a similar experi-ence some 15 years ago, before the days oftransistor radios or even of jet aircraft. Sheawoke suddenly about 3 a.m. to find that thetop part of the tumbler of water beside herbed had completely shattered, leaving onlythe base standing with a sharp, jagged edgeall the way round. Her first thought wasthat she had hit it with her hand in her sleep,but as her hand was uninjured this wasimpossible. She is not aware that there wereany sources of high-frequency sounds in thevicinity.

Glass objects sometimes crack or splinterspontaneously from strains set up duringmanufacture, but this does not seem to bethe whole story. There are reports ofmotorists' windscreens shattering on passinga certain point on the road. A few yearsago there was quite an epidemic of this kind-if I remember correctly, on the London-Portsmouth road near Esher. Over a periodof several weeks numerous motorists reportedshattering of their windscreens, all along thesame stretch of road. Then the phenomenonceased as suddenly as it had begun. As faras I know it was never satisfactorily ex-plained. "There are more things in heavenand earth . ."-I am, etc.,Geneva. A. M. WOOLMAN.

Diagnosis of Hepatic AmoebiasisSIR,-I was interested to read the article

of Dr. T. Doxiades and his colleagues onchronic amoebic hepatitis (8 February, p.343). Amoebiasis is quite common in thiscountry, and I have frequently observed themedial bulge of the diaphragm in the casesof amoebic hepatitis. However, a useful signthat I have noted is that there is tendernesspresent on deep pressure in the intercostalspaces over the liver, even if there is no, orequivocal, tenderness present by the usualmethod of examination of the liver.-I am,etc.,Gulabdevi Chest Hospital, T. D. AGGARWAL.Jullundur, India.

Pathogenesis of Atherosclerosis

SIR,-Dr. J. L. Edwards in his letter (7March, p. 629) asks why the portion of theleft descending coronary artery is calcified infour out of five fatal myocardial infarcts.Presumably these myocardial infarcts had re-sulted in sudden death in the street, at publicfunctions, or in other public places, and someof them occurred in patients already in hos-pital. Was the ratio of outside deaths to hos-pital deaths four to one ? Can it be that thesudden coronary deaths are those with thiscalcified artery, and the other people whomwe see and treat, and who survive for longafter the original attack, either do not developcalcification or have not done so when first

we are called to them ? If this is the casethe ratio of four to one referred to by Dr.Edwards is not really significant because itexcludes all the survivors whom he may neversee because they die in their beds.Development of this argument prompts

another question-does myocardial infarctionperhaps result from one of two principalcauses, either gradual and progressive anoxiain a calcifying artery, or thrombosis due toan altered state of blood in a comparativelypatent coronary system ? This dual aetiologywould agree with not only the pathologists'findings but also with the clinicians' experi-ence.-I am, etc.,

Tarbert, A. C. MAYER.Loch Fyne, Argyll.

Dental AnaesthesiaSIR,-With reference to Mr. Eric Scho-

field's letter (28 March, p. 837) I have beengiving about 30 dental anaesthetics a weeksince 1952, and it is upon this experiencethat I base the following remarks.

I cannot agree that intravenous anaesthesia,given intermittently, is a safe technique inoperations on the nose, mouth, or pharynx,unless the air passages are secured by theuse of an endotracheal technique. Intravenousdrugs also have the disadvantage that one isalways meeting the old unsuspected patientwho metabolizes the injected drug very slowly,whereas an inhalation anaesthetic can bequickly removed from the patient by simpleventilation with oxygen. Halothane withadequate oxygen is a pleasant method ofinduction, and I find that children who havenot previously had bad experiences oftenprefer it.

I find that for major dental work an intra-venous dose of atropine, followed by endo-tracheal oxygen and halothane, and a goodpharyngeal pack, gives a satisfactory " air-way" and a pink patient, together withcomplete protection against the aspiration offoreign bodies.

I do this manceuvre successfully in thedental surgeon's consulting-room, and therecovery time is not much longer than it iswith the bad old anoxic nitrous oxide.

However, I must conclude by agreeing withMr. Schofield's remarks about the DentalEstimates Board, and by expressing theopinion that in a civilized country anaes-thetics are really the province of the trainedanaesthetist, in the same way that dentaloperations are really the province of thedental surgeon.-I am, etc.,

Bath, Somerset. J. R. J. BEDDARD.

SIR,-While supporting fully the proposalof Dr. J. G. Bourne (14 March, p. 696) forestablishing a first-class dental clinic in everyhospital group, so that future anaesthetistswill be well acquainted with modem methodsof general anaesthesia as used in dental cases,I want to make a plea for a reduction in theroutine use of general anaesthesia for dentalcases.

There are many justifications for givinggeneral anaesthesia in some cases and forsome major surgeries, but to make it routinefor all children's extractions or doing the so-called " clearances," and, to take on theprocess very lightly (as one can see from the

frequently used expression "Just a whiff ofgas and it will be out ") is not conducive inthe long run to good dental health-aspatients who have been used to having gasare unlikely to sit down happily in the dentalchair to have their necessary fillings done.

Local anaesthesia especially, taking intoaccount the excellent, harmless, and powerfulbrands of the local anaesthetics available now,is preferable to general anaesthesia even incases of impacted wisdoms, buried roots, andany but the largest of cysts in the vastmajority of patients, and there is certainly nojustification for the use of general anaesthesiafor routine dental work-e.g., extractions andfillings-except in the very young, or in veryhighly strung individuals.

Let us recognize the value of localanaesthetics, with whikh a painless and time-consuming operation could be done on a fullyalert and co-operative patient. I have foundthat many patients prefer local anaesthetic fortheir extractions after they have been having" gas " on previous occasions, and many werechildren. The only drawback of local anaes-thesia is the fact that fewer extractions can bedone in one sitting; this to my mind is agood thing if the patients' well-being is ourprime concern.-I am, etc.,

Leeds 6. A. A. UTHMAN.

SIR,_-I was astounded by the secondsentence in Dr. J. G. Bourne's letter on dentalanaesthesia (14 March, p. 696) in which hestates: " It is common knowledge that themethods in general use in dentistry are relicsof Victorian practice and, by modernstandards, anything but satisfactory."

In this area practically all dentists havemodem McKesson or Walton gas-oxygenmachines, with trichloroethylene (" trilene ")or halothane (" fluothane ") attachments. Theminor extraction cases are anaesthetized,usually very successfully and pleasantly forthe patients, by the dental surgeons; for fullclearances, or anticipated difficult cases, theusual technique practised by most local anaes-thetists is induction by intravenous thiopen-tone (" intraval ") for a powerful man, ormethohexitone (" brietal ") for a woman, withmaintenance by nitrous oxide and oxygen,supplemented if necessary by trichloro-ethylene. In a very few difficult casesintubation is necessary for smooth anaesthesia.Some dental surgeons and anaesthetist use

halothane with nitrous oxide and oxygen for