First gastrectomy 1964


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First gastrectomy 1964

  1. 1. 1044 18 April 1964 Correspondenceno knowledge as to whether it is a widely For the explanation of how cartilage Treatment of Dumping Syndromerecognized occurrence. manages, with its feeble sponge skeleton, to Last year I was treating an elderly lady recover the fluid which is squeezed out under SIR,-In answer to your correspondentwho suffered from congestive heart failure load, may I refer your readers to an article Dr. Steven S. Smith (28 March, p. 835)and severe osteoarthritis of her knees. Oral in the New Scientist ?P-I am, etc., about the lack of a " central bureau of in-diuretics were insufficient to control the ex- C. W. MCCUTCHEN. formation " on syndromes after gastrectomy,tensive oedema of her legs and it seemed Laboratory of Experimental Pathology, there are, of course, innumerable articles ondesirable to reinforce this with weekly injec- National Institute of Arthritis and post-gastrectomy syndromes listed in thetion of " neptal " (o-(2-hydroxy-3-hydroxy- Metabolic Diseases, Cumulative Index Medicus, Current List of Bethesda 14,mercuripropylcarbomyl) phenoxyacetic acid Maryland, U.S.A. Medical Literature, and the Index Medicusand theophylline). This produced a satisfac- fairly soon after they appear, which he can REFERENCE refer to if he has access to these tomes. Iftory diminution in the oedema, but it becamevery evident that on each occasion it was McCutchen, C. W., New Scientist, 1962, 15, 412. not, then reviews appear from time to timeaccompanied by exacerbation of the pain in on this as on so many subjects, summarizingher knees, which improved as the oedema re- medical information to date.formed in the course of the next few days. The Birmingham School of Medicine has SIR,-In a letter which you published on been very much concerned with these syn- Your article suggests that the lubrication 28 March (p. 835) Mr. D. B. Welbournof joints depends on the viscosity of the syn- dromes over the past 15 years and two mono- remarks that he has never seen the " squish" graphs have recently been published whichovial fluid rather than on the quantity, but bearing discussed in engineering literature.the inference I drew from my patient was should be of help. He will find reviews ofthat the bone surfaces were being kept separ- May I refer him to H. W. Swift,," Fluctu- his particular problem in Dr. C. F. Hawkinssated by an increased volume of intra-articular ating Loads in Sleeve Bearings " (7. Inst. civil book Diseases of the Alimentary Tract (chap-fluid, as part of the general oedema of the Engineers, February 1937). This paper gives ter V, " gastric operations and their meta-leg, and that the diuretic produced a relative a fairly extensive theory for a bearing pin bolic sequelae ") (London, Heinemann, 1963)intra-articular dehydration and consequent moving about in the clearance space of an and in Partial Gastrectomy (Stammers andfriction. At all events the patient was grate- oil-filled bearing bush, both without and with Williams) (London, Butterworths, 1963). Theful when I treated her oedema less diligently. rotation of the pin.-I am, etc., problem of the use of antibacterial agents is-I am, etc., Bedford. A. C. HUTCHINSON. here specifically referred to in chapter 10, Tunbridge Wells, A. CAMERON. " Under-nutrition, malnutrition, and mal- Kent. absorption after gastrectomy."-I am, etc., Queen Elizabeth Hospital. J. M. FRENCH. SIR,-Your leading article " Lubrication Latex Fixation in Liver Disease Birmingham 15.of Joints " (15 February, p. 384) contains SIR,-We were interested in your leadinga good account of the paradox which results article (28 March, p. 794) because we havewhen one tries to account for joint behaviour been trying to assess the value of the terms of classical engineering. However, latex test in diagnosis of liver disease and When was the First Gastrectomy ?its precis of weeping lubrication is incorrect. especially jaundice. So far we have tested The article states, " On this theory the the serum from 71 patients, and the results SIR,-In his review (7 March, p. 623) ofarticular cartilage exudes lubricant in advance are as follows: Gastric Surgery. Errors, Safeguards andof the point of pressure, encouraging hydro- Management of Malfunction Syndromes, bydynamic lubrication at the point of contact." Moses E. Steinberg (1963), Sir CharlesWhile the squeezing out of liquid ahead of Total Positive Negative Illingworth writes, " The first part of thisthe area of contact undoubtedly occurs to Cholecystitis (without book reviews at some length the history ofsome degree, it can only be of the minutest jaundice) .. .. 15 0 15 gastric surgery, from the first gastro-importance in lubrication, because this region Extrahepatic obstructive jejunostomy performed by Wolfler in 1881 jaundice .. .. 17 1 16is already wet. Intrahepatic obstructive and the first gastrectomy by Rydygier in What is important is that the spongy struc- jaundice .. .. 18 7 11 1882. . . ." Portal cirrhosis .. .. 21 15 6ture of cartilage automatically provides But according to Aird the Billroth Ihydrostatic (not hydrodynamic) lubrication. operation was the first successful gastrectomy.This is because the sponge skeleton is very As yet we have found no consistent pattern It was first successfully performed by Billrothweak in compression. Were the liquid con- of reaction in the conditions which make up in 1881, but had previously been unsuccess-tained within the cartilage free to move the intrahepatic group, such as infective fully attempted by Pean. Farquharson alsothrough the sponge skeleton without viscous hepatitis, drug jaundice, and chronic intra- gives 1881 as the year of Billroths firstresistance it would be expelled immediately hepatic obstructive jaundice (" primary operation.upon application of load, leaving the cartilage biliary cirrhosis "), and the high proportion Maingot records, " Pean (Gaz. Hop. Paris,squashed down solid at about half its original of negative results is disappointing. On the 1879, 52, 473) at the Hospital of Saint Louisthickness. In fact the pore size is so small, other hand a positive test in obstructive performed the first recorded pyloric resectionand the viscous resistance correspondingly so jaundice almost certainly excludes an extra- for carcinoma on a human. His patient diedlarge, that expulsion of the liquid takes hepatic cause. We can also confirm the on the fifth post-operative day. Rydygierseveral hours. strong reactions that occur in patients with (Arch. klin. Chir., 1881, 26, 731), on 16 During this period the load is carried portal cirrhosis who show signs of active November 1880, performed the secondpartly by hydrostatic pressure in the liquid disease such as jaundice, ascites, and hepatic pyloric resection on a human for carcinoma and partly by elastic forces in the sponge failure. of the pylorus. He re-established continuity skeleton. To an animal it is the first few Like Dr. I. A. D. Bouchier and his col- by gastroduodenal anastomosis with a series minutes which matter, and then the load is leagues (7 March, p. 592), whose article your of interrupted silk sutures. This patient carried almost entirely (and almost friction- leader writer appears to have ignored, we collapsed and died some 12 hours following lessly) by the liquid because the skeleton will have excluded weakly positive reactions. But the operation. be but slightly deformed. we have been struck by their frequency in this " The first successful resection for cancer of You also state, presumably as a weakness group of patients, and it may be that quanti- the stomach was accomplished by Billroth in in the case for weeping lubrication, that it is tative methods should be employed to estab- 1881 (Wein. med. Wschr., 1881, 31, 161). not established whether the hyaluronic acid of lish the significance of R.A. latex fixation in Rydygier (1881) stated that Billroth per- synovial fluid is found within articular carti- liver disease.-We are, etc., formed the third pylorectomy with gastro- lage. It is likely that it will not be. The duodenostomy for an obstructing carcinoma pores of cartilage seem too small to admit the Dudley Road Hospital, P. R. BUTLER. of the pylorus in the human. Billroth had large polymer molecules. The liquid in Birmingham 18. A. PATON. no knowledge of Rydygiers case when he cartilage would thus be an ultrafiltrate of successfully carried out this operation on synovial fluid, but it would be liquid none *** We regret omitting reference to the 29 January 1881. The patient was a woman the less and perfectly able to carry load by paper by I. A. D. Bouchier et al.-ED., aged 43 and the pyloric tumour was mobile hydrostatic pressure. B.M.7. and lent itself readily to resection. She un-
  2. 2. 18 April 1964 Correspondence BRITISH MEDICAL JOURNAL 14 1045 fortunately died four months after the Pathogenesis of Atherosclerosis we are called to them ? If this is the case operation from liver metastases." the ratio of four to one referred to by Dr. Which is correct ?-I am, etc., SIR,-Dr. J. L. Edwards in his letter (7 Edwards is not really significant because it March, p. 629) asks why the portion of the excludes all the survivors whom he may never North Ormesby Hospital, S. D. SARKAR. left descending coronary artery is calcified in see because they die in their beds. Middlesbrough. four out of five fatal myocardial infarcts. Development of this argument prompts REFERENCES Presumably these myocardial infarcts had re- Aird, I., A Companion in Surgical Studies, 2nd sulted in sudden death in the street, at public another question-does myocardial infarction ed., 1957, p. 772. Livingstone, Edinburgh. perhaps result from one of two principal 2 Farquharson, E. L., Textbook of Operative Sur- functions, or in other public places, and some gery, 2nd ed., 1962, p. 526. Livingstone, of them occurred in patients already in hos- causes, either gradual and progressive anoxia Edinburgh. in a calcifying artery, or thrombosis due to 3Maingot, R., Abdominal Operations, 4th ed., pital. Was the ratio of outside deaths to hos- an altered state of blood in a comparatively 1961, p. 203. Appleton Century Crofts, New pital deaths four to one ? Can it be that the York. patent coronary system ? This dual aetiology sudden coronary deaths are those with this would agree with not only the pathologists calcified artery, and the other people whom findings but also with the clinicians experi- Bedside Hazard we see and treat, and who survive for long ence.-I am, etc., after the original attack, either do not develop A. C. MAYER. Tarbert, SIR,-Your number of 1 February has calcification or have not done so when first Loch Fyne, Argyll. only just come to my attention, and I hope it is not too late to comment on Dr. P. M. Corkeys interesting letter on " Bedside Hazard " (p. 311). He suggests that the shattering of a tumbler beside the bed was Dental Anaesthesia caused by the sound waves emitted by a small SIR,-With transistor radio, the volume of which was fields letter reference to Mr. Eric Scho- frequently used expression "Just a whiff of turned right down. If the volume was giving about(28 March, p. 837) I have week gas and it run be out ") isdentalconducive in 30 dental anaesthetics a been the long will to good not health-as turned down, the energy of any sound waves since 1952, and it is upon this experience patients who have been used to having gas would have been correspondingly reduced, that I base the following remarks. are unlikely to sit down happily in the dental and it is difficult to believe that it could have I cannot agree that intravenous anaesthesia, chair to have their necessary fillings done. been sufficient to shatter the glass. given intermittently, is a safe technique in Local anaesthesia especially, taking into My scepticism is heightened by the fact operations on that a colleague of mine had a similar experi- unless the air the nose, mouth, or pharynx, brands of the local anaesthetics available passages are secured by the account the excellent, harmless, and powerful ence some 15 years ago, before the days of use of an endotracheal technique. Intravenous is preferable to general anaesthesia even in now, transistor radios or even of jet aircraft. She drugs also have the disadvantage that one is cases of impacted wisdoms, buried roots, and awoke suddenly about 3 a.m. to find that the always meeting the old unsuspected top part of the tumbler of water beside her who metabolizes the injected drug very patient majority of patients, and there is in the vast slowly, any but the largest of cysts certainly no bed had completely shattered, leaving only whereas an inhalation anaesthetic can be justification for the use of general anaesthesia the base standing with a sharp, jagged edge quickly removed from the patient by simple for routine dental work-e.g., all the way round. Her first thought was ventilation with extractions and that she had hit it with her hand in her sleep, adequate oxygen oxygen. Halothane with fillings-except in the very young, or in very is but as her hand was uninjured this was induction, and I find a pleasant method of highly strung individuals. impossible. She is not aware that there were not previously had that children who often anaesthetics, recognize the painless and time- bad experiences have Let us with whikh a value of local any sources of high-frequency sounds in the prefer it. vicinity. consuming operation could be done on a fully I find that for major dental work an Glass objects sometimes crack or splinter venous dose of atropine, followed by intra- alert and co-operative patient. I have found spontaneously from strains set up during tracheal oxygen and halothane, and a endo- their many patients prefer local anaesthetic for good that extractions after they have manufacture, but this does not seem to be pharyngeal pack, gives a satisfactory " air- " gas " on previous occasions, andbeen having many were the whole story. There are reports of way" and a pink patient, together with children. The motorists windscreens shattering on passing complete protection against the aspiration of thesia is the only drawback of local anaes- a certain point on the road. A few years foreign bodies. fact that fewer extractions can be ago there was quite an epidemic of this kind done in one sitting; this to my mind is a I do this manceuvre successfully in the -if I remember correctly, on the London- dental surgeons consulting-room, and the good thing if the patients well-being is our Portsmouth road near Esher. Over a period recovery time is prime concern.-I am, etc., of several weeks numerous motorists reported with the bad old not much longer than it is anoxic nitrous oxide. Leeds 6. A. A. UTHMAN. shattering of their windscreens, all along the However, I must conclude by agreeing with same stretch of road. Then the phenomenon Mr. Schofields remarks about the Dental ceased as suddenly as it had begun. As far Estimates Board, and by expressing the SIR,_-I was astounded by the second as I know it was never satisfactorily ex- opinion that in a civilized country anaes- sentence in Dr. J. G. Bournes letter on dental plained. "There are more things in heaven thetics are really the province of the trained anaesthesia (14 March, p. 696) in which he and earth . ."-I am, etc., anaesthetist, in the same way that dental states: " It is common knowledge that the Geneva. A. M. WOOLMAN. operations are really the province of the methods in general use in dentistry are relics dental surgeon.-I am, etc., of Victorian practice and, by modern standards, anything but satisfactory." Bath, Somerset. J. R. J. BEDDARD. In this area practically all dentists have Diagnosis of Hepatic Amoebiasis modem McKesson or Walton gas-oxygen machines, with trichloroethylene (" trilene ") SIR,-I was interested to read the article SIR,-While supporting fully the proposal or halothane (" fluothane ") attachments. Theof Dr. T. Doxiades and his colleagues on of Dr. J. G. Bourne (14 March, p. 696) for minor extraction cases are anaesthetized,chronic amoebic hepatitis (8 February, p. establishing a first-class dental clinic in every usually very successfully and pleasantly for343). Amoebiasis is quite common in this hospital group, so that future anaesthetists the patients, by the dental surgeons; for fullcountry, and I have frequently observed the will be well acquainted with modem methods clearances, or anticipated difficult cases, themedial bulge of the diaphragm in the cases of general anaesthesia as used in dental cases, usual technique practised by most local anaes-of amoebic hepatitis. However, a useful sign I want to make a plea for a reduction in the thetists is induction by intravenous thiopen-that I have noted is that there is tenderness routine use of general anaesthesia for dental tone (" intraval ") for a powerful man, orpresent on deep pressure in the intercostal cases. methohexitone (" brietal ") for a woman, withspaces over the liver, even if there is no, or There are many justifications for giving maintenance by nitrous oxide and oxygen,equivocal, tenderness present by the usual general anaesthesia in some cases and for supplemented if necessary by trichloro-method of examination of the liver.-I am, some major surgeries, but to make it routine ethylene. In a very few difficult casesetc., for all childrens extractions or doing the so- intubation is necessary for smooth anaesthesia. Gulabdevi Chest Hospital, T. D. AGGARWAL. called " clearances," and, to take on the Some dental surgeons and anaesthetist use Jullundur, India. process very lightly (as one can see from the halothane with nitrous oxide and oxygen for