1. 1044 18 April 1964 Correspondence
no knowledge as to whether it is a widely For the explanation of how cartilage Treatment of Dumping Syndrome
recognized 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 correspondent
who 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 on
desirable to reinforce this with weekly injec- National Institute of Arthritis and post-gastrectomy syndromes listed in the
tion 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 Medicus
and theophylline). This produced a satisfac- fairly soon after they appear, which he can
REFERENCE refer to if he has access to these tomes. If
tory diminution in the oedema, but it became
very evident that on each occasion it was McCutchen, C. W., New Scientist, 1962, 15, 412. not, then reviews appear from time to time
accompanied by exacerbation of the pain in on this as on so many subjects, summarizing
her 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. Welbourn
of 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 which
ovial 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 of
that the bone surfaces were being kept separ- May I refer him to H. W. Swift,," Fluctu- his particular problem in Dr. C. F. Hawkins's
ated 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 and
friction. At all events the patient was grate- oil-filled bearing bush, both without and with Williams) (London, Butterworths, 1963). The
ful 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 leading
a good account of the paradox which results article (28 March, p. 794) because we have
when one tries to account for joint behaviour been trying to assess the value of the R.A.
in 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) of
articular cartilage exudes lubricant in advance are as follows: Gastric Surgery. Errors, Safeguards and
of the point of pressure, encouraging hydro- Management of Malfunction Syndromes, by
dynamic lubrication at the point of contact." Moses E. Steinberg (1963), Sir Charles
While the squeezing out of liquid ahead of Total Positive Negative Illingworth writes, " The first part of this
the area of contact undoubtedly occurs to Cholecystitis (without book reviews at some length the history of
some 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 16
is 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 6
ture of cartilage automatically provides But according to Aird' the Billroth I
hydrostatic (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 Billroth
weak 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' also
through the sponge skeleton without viscous hepatitis, drug jaundice, and chronic intra- gives 1881 as the year of Billroth's first
resistance 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 Louis
thickness. In fact the pore size is so small, other hand a positive test in obstructive performed the first recorded pyloric resection
and the viscous resistance correspondingly so jaundice almost certainly excludes an extra- for carcinoma on a human. His patient died
large, that expulsion of the liquid takes hepatic cause. We can also confirm the on the fifth post-operative day. Rydygier
several 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 second
partly 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 Rydygier's 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. 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.
Corkey's 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 field's 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 surgeon's 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. Schofield's 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. Bourne's 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. The
of 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 for
343). Amoebiasis is quite common in this hospital group, so that future anaesthetists the patients, by the dental surgeons; for full
country, and I have frequently observed the will be well acquainted with modem methods clearances, or anticipated difficult cases, the
medial 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, or
present on deep pressure in the intercostal cases. methohexitone (" brietal ") for a woman, with
spaces 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 cases
etc., for all children's 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