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MEASURED RADICAL GASTRECTOMY
651 rheumatism," and it is to be hoped that the recommendations of the Ministry of Health’s advisory committee will
be’put into effect without unnecessary delay. If the best is to be got out of any scheme the eager and enthusiastic cooperation of the general practitioner must be a sine qua non. At the present time most, practitioners are rather at sea in differentiating the various types of rheumatism and the present-day means employed for their alleviation. Dr. Buckley’s suggestion last week
that weekend courses with clinical demonstrations should be organised by the large provincial hospitals for practitioners living in their district will be welcomed by all. J. H. DUNN. London, S.W.I. A BROKEN BACK SiR,—This article, in your issue of April 3, gives a picture of spiritual valour against overwhelming physical odds that must be rarely equalled. The account of the way in which the authoress was able to defy each handicap as it arose, and so to find life worth while and its pleasures still within reach, is a most absorbing tale. It should be an inspiration, too, to others, who may ’ have faltered before physical disabilities far smaller than those faced bv the writer of this article. CHARLES CORFIELD. Bristol. FOR AND AGAINST MYANESIN SIR,-In your leading article of March 27 you expressed the opinion that the recent clinical observations 12 on the central depressant effect and the lack of curare action of ’Myanesin ’ constituted a serious criticism. The central depressant effect and the lack of peripheral action (in therapeutic or tolerated doses) have been stressed in the first publication on this subject,3 reiterated in your columns, and commended in your leading article on Jan. 18, 1947. Myanesin is not employed " in anaesthesia merely to potentiate mildly the narcotic drug which must be given at the same time " as you state. The use of myanesin during anaesthesia was recommended on the basis of the
following considerations.5 During light anaesthesia, due
to the release of subcortical centra from the control of the cortex there is marked hyperexcitability of the spinal and bulbar reflexes. At this level . of anaesthesia the patient is unconscious but operative procedures cannot be carried out because of the hyperactivity of these defence mechanisms. Myanesin selectively depresses the hyperexcitability of the spinal reflexes, and, for this reason, permits the performance of operations at a lighter level of anaesthesia than would be possible in the absence of the drug. The paralysing action occurring after large doses (also due to the depressant action on the central nervous system) need not be made use of, as satisfactory relaxation usually occurs after hyperexcitability has been abolished. Synergism between the narcotic drug and myanesin is also likely to be of minor significance in the production of muscular relaxation.
Concerning the relative ineffectiveness of myanesin in muscle spasm, it is well to keep in mind that curare relaxes muscular spasms only in doses which paralyse,s whereas myanesin abolishes spasms in doses which do not diminish voluntary muscular power.55 The efficacy of myanesin in ’relieving tetanic spasms was more pronounced than that of curare.’7 Schlesinger et al.,8 who had extensive experience with both curare and appraised myanesin as follows : " Its efficiency myanesin, in ameliorating involuntary movements, rigidity, spasticity, and tremor are of a higher order than that of the curare series, and at least comparable to any known therapeutic agent." Myanesin passed the crucial test of the specific relaxing effects of such drugs on voluntary muscle, in producing the desired action without the support of any accompanying narcotic. Because of the low solubility and the necessity of using solvents, myanesin in 10 % solution may have caused 1.
Stephen, C. R., Chandy, J. Canad. med. Ass. J. 1947, 57, 463. Hunter, A. R., Waterfall, J. M. Lancet, March 6, p. 366. 3. Berger, F. M., Bradley, W. Brit. J. Pharmacol. 1946, 1, 265. 4. Berger, F. M., Bradley, W. Lancet, 1947,i, 97. 5. Berger, F.M. Brit. J. Pharmacol. 1947, 2, 241. 6. West, R. Proc. R. Soc. Med. 1935, 28, 565. 7. Beltrage, D. H. Lancet, 1947, ii, 889. 8. Schlesinger, E. B., Drew, A. L., Wood, B. Amer. J. Med. 1948, 2.
4, 365.
haemoglobinuria in 20 out of 10,000 patients, but did not cause respiratory paralysis. With curare peripheral respiratory paralysis occurs in the majority of cases and is dangerous even when efficiently managed.6 It may well be that the mortality from curare during anaesthesia is greater than the incidence -of heemoglobinuria after myanesin. Myanesin administered intravenously in saturated aqueous solutions does not even cause haemolysis or thrombosis. Myanesin can also be safely administered by other routes. The dramatic effects obtained with myanesin in a variety of previously intractable conditions makes it certain that there will be a definite place in therapeutics for agents with a similar F. M. BERGER. type of action. University of Rochester School of Medicine and Dentistry, Rochester, New York.
SIR,-In last week’s issue Mr. Vartan,
as a
gyneecolo-
He claims that the relaxation obtained is comparable to that associated with spinal analgesia. I have observed this in a very much larger series of cases; but in some exactly comparable cases, where every detail of technique was identical, relaxation was absent or poor, or vanished at the slightest surgical trauma to the parietal peritoneum. Unpredictable action is the strongest argument against the use of any
gist,
gave his views on’Myanesin.’
drug.
In my series there was 1 proved case of methaemoglobinuria and 2 of venous thrombosis-one minor and the other very serious. I cannot accept Mr. Vartan’s suggestion that this is a matter of technique. The late Cecil Joll, himself a superb technician, once said to me that all intravenous injections should be given by anaesthetists since they were the only people who knew how. I would suggest that any" aneasthetists who " have not the hands would better serve the interests of their necessary for it fellow men by volunteering for work on the land or down the coal-mines. Aylesbury.
LOFTUS DALE.
MEASURED RADICAL GASTRECTOMY
SiR,-The article by Mr. Hedley Visick (April 3 and 10) raises several
points of great interest in gastric surgery. Leaving a gastric pouch of a known size makes the subsequent history of such cases of real scientific value ; and dividing the vasa brevia not only permits removal of more of the greater curvature where the mucosal folds are most marked, but combined with high division of the left gastric artery also allows the stomach to rotate on the oesophagus, thus facilitating the anastomosis. Since watching Mr. Visick, I have adopted with advantage cutting of the vasa brevia to the Bilroth i operation-which I still regard as the most suitable type of partial gastrectomy for gastric ulcer. There is no doubt that the stomach can be widely devascularised without danger, but there are definite limitations. Necrosis of the mucous membrane and even sloughing on the posterior wall of the stomach have been known to follow gastric ligation. Visick has claimed that secondary ulceration will not follow if part of the antrum is left in cases where removal of the duodenal ulcer would be dangerous. If this is found to be correct, then measured partial gastrectomy will be a distinct advance, but unfortunately the pyloric antrum is such a strong stimulus in producing recurrent ulceration that it will require a much larger series than his 12 cases to carry conviction. The results of partial gastrectomy are so good that there is a tendency to ignore the small percentage of disappointing results, especially in those cases which develop the postoperative symptoms of the so-called dumping syndrome.’These symptoms may be so mild as to be ignored by the patient, or severe enough to be a major disability ; they occur after all types of partial gastrectomy, but tend to disappear in time. Sometimes variations in the sugar content of the blood offer a sufficient explanation, but usually the cause remains
unexplained.
Mr. Visick’s article shows the necessity for follow-up clinics in gastric surgery, not only as a means of investigation but as the first step towards the treatment of postoperative symptoms. PETER G. MCEVEDY. Manchester.
be’put into effect without unnecessary delay. If the best is to be got out of any scheme the eager and enthusiastic cooperation of the general practitioner must be a sine qua non. At the present time most, practitioners are rather at sea in differentiating the various types of rheumatism and the present-day means employed for their alleviation. Dr. Buckley’s suggestion last week
that weekend courses with clinical demonstrations should be organised by the large provincial hospitals for practitioners living in their district will be welcomed by all. J. H. DUNN. London, S.W.I. A BROKEN BACK SiR,—This article, in your issue of April 3, gives a picture of spiritual valour against overwhelming physical odds that must be rarely equalled. The account of the way in which the authoress was able to defy each handicap as it arose, and so to find life worth while and its pleasures still within reach, is a most absorbing tale. It should be an inspiration, too, to others, who may ’ have faltered before physical disabilities far smaller than those faced bv the writer of this article. CHARLES CORFIELD. Bristol. FOR AND AGAINST MYANESIN SIR,-In your leading article of March 27 you expressed the opinion that the recent clinical observations 12 on the central depressant effect and the lack of curare action of ’Myanesin ’ constituted a serious criticism. The central depressant effect and the lack of peripheral action (in therapeutic or tolerated doses) have been stressed in the first publication on this subject,3 reiterated in your columns, and commended in your leading article on Jan. 18, 1947. Myanesin is not employed " in anaesthesia merely to potentiate mildly the narcotic drug which must be given at the same time " as you state. The use of myanesin during anaesthesia was recommended on the basis of the
following considerations.5 During light anaesthesia, due
to the release of subcortical centra from the control of the cortex there is marked hyperexcitability of the spinal and bulbar reflexes. At this level . of anaesthesia the patient is unconscious but operative procedures cannot be carried out because of the hyperactivity of these defence mechanisms. Myanesin selectively depresses the hyperexcitability of the spinal reflexes, and, for this reason, permits the performance of operations at a lighter level of anaesthesia than would be possible in the absence of the drug. The paralysing action occurring after large doses (also due to the depressant action on the central nervous system) need not be made use of, as satisfactory relaxation usually occurs after hyperexcitability has been abolished. Synergism between the narcotic drug and myanesin is also likely to be of minor significance in the production of muscular relaxation.
Concerning the relative ineffectiveness of myanesin in muscle spasm, it is well to keep in mind that curare relaxes muscular spasms only in doses which paralyse,s whereas myanesin abolishes spasms in doses which do not diminish voluntary muscular power.55 The efficacy of myanesin in ’relieving tetanic spasms was more pronounced than that of curare.’7 Schlesinger et al.,8 who had extensive experience with both curare and appraised myanesin as follows : " Its efficiency myanesin, in ameliorating involuntary movements, rigidity, spasticity, and tremor are of a higher order than that of the curare series, and at least comparable to any known therapeutic agent." Myanesin passed the crucial test of the specific relaxing effects of such drugs on voluntary muscle, in producing the desired action without the support of any accompanying narcotic. Because of the low solubility and the necessity of using solvents, myanesin in 10 % solution may have caused 1.
Stephen, C. R., Chandy, J. Canad. med. Ass. J. 1947, 57, 463. Hunter, A. R., Waterfall, J. M. Lancet, March 6, p. 366. 3. Berger, F. M., Bradley, W. Brit. J. Pharmacol. 1946, 1, 265. 4. Berger, F. M., Bradley, W. Lancet, 1947,i, 97. 5. Berger, F.M. Brit. J. Pharmacol. 1947, 2, 241. 6. West, R. Proc. R. Soc. Med. 1935, 28, 565. 7. Beltrage, D. H. Lancet, 1947, ii, 889. 8. Schlesinger, E. B., Drew, A. L., Wood, B. Amer. J. Med. 1948, 2.
4, 365.
haemoglobinuria in 20 out of 10,000 patients, but did not cause respiratory paralysis. With curare peripheral respiratory paralysis occurs in the majority of cases and is dangerous even when efficiently managed.6 It may well be that the mortality from curare during anaesthesia is greater than the incidence -of heemoglobinuria after myanesin. Myanesin administered intravenously in saturated aqueous solutions does not even cause haemolysis or thrombosis. Myanesin can also be safely administered by other routes. The dramatic effects obtained with myanesin in a variety of previously intractable conditions makes it certain that there will be a definite place in therapeutics for agents with a similar F. M. BERGER. type of action. University of Rochester School of Medicine and Dentistry, Rochester, New York.
SIR,-In last week’s issue Mr. Vartan,
as a
gyneecolo-
He claims that the relaxation obtained is comparable to that associated with spinal analgesia. I have observed this in a very much larger series of cases; but in some exactly comparable cases, where every detail of technique was identical, relaxation was absent or poor, or vanished at the slightest surgical trauma to the parietal peritoneum. Unpredictable action is the strongest argument against the use of any
gist,
gave his views on’Myanesin.’
drug.
In my series there was 1 proved case of methaemoglobinuria and 2 of venous thrombosis-one minor and the other very serious. I cannot accept Mr. Vartan’s suggestion that this is a matter of technique. The late Cecil Joll, himself a superb technician, once said to me that all intravenous injections should be given by anaesthetists since they were the only people who knew how. I would suggest that any" aneasthetists who " have not the hands would better serve the interests of their necessary for it fellow men by volunteering for work on the land or down the coal-mines. Aylesbury.
LOFTUS DALE.
MEASURED RADICAL GASTRECTOMY
SiR,-The article by Mr. Hedley Visick (April 3 and 10) raises several
points of great interest in gastric surgery. Leaving a gastric pouch of a known size makes the subsequent history of such cases of real scientific value ; and dividing the vasa brevia not only permits removal of more of the greater curvature where the mucosal folds are most marked, but combined with high division of the left gastric artery also allows the stomach to rotate on the oesophagus, thus facilitating the anastomosis. Since watching Mr. Visick, I have adopted with advantage cutting of the vasa brevia to the Bilroth i operation-which I still regard as the most suitable type of partial gastrectomy for gastric ulcer. There is no doubt that the stomach can be widely devascularised without danger, but there are definite limitations. Necrosis of the mucous membrane and even sloughing on the posterior wall of the stomach have been known to follow gastric ligation. Visick has claimed that secondary ulceration will not follow if part of the antrum is left in cases where removal of the duodenal ulcer would be dangerous. If this is found to be correct, then measured partial gastrectomy will be a distinct advance, but unfortunately the pyloric antrum is such a strong stimulus in producing recurrent ulceration that it will require a much larger series than his 12 cases to carry conviction. The results of partial gastrectomy are so good that there is a tendency to ignore the small percentage of disappointing results, especially in those cases which develop the postoperative symptoms of the so-called dumping syndrome.’These symptoms may be so mild as to be ignored by the patient, or severe enough to be a major disability ; they occur after all types of partial gastrectomy, but tend to disappear in time. Sometimes variations in the sugar content of the blood offer a sufficient explanation, but usually the cause remains
unexplained.
Mr. Visick’s article shows the necessity for follow-up clinics in gastric surgery, not only as a means of investigation but as the first step towards the treatment of postoperative symptoms. PETER G. MCEVEDY. Manchester.