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CYCLIC VOMITING.
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retaining the services of orthopaedic surgeons there is THE DISSOLUTION OF INSULIN. little danger of unsuitable limbs being supplied. It 2’0 the Editor of THE LANCET. would, however, undoubtedly be a boon to other SIR,—In view of Dr. R. D. Lawrence’s interesting civilian amputees if some plan existed by which the letter I am pleased to give to readers of THE LANCET patient could enjoy the combined skill of surgeon and limb-maker, although we doubt whether the number of a few more details of my recent work. Commercial insulin seems to be composed of at cases would warrant the establishment of a fitting least three substances-viz., the true pancreatic centre. At the Queen Mary’s Convalescent Auxiliary hormone A, the anti-insulin B, and co-insulin C. Of Hospital, Roehampton, the fitting is restricted to one these substances A and B have been obtained in or two firms, and the patient does not have a perfectly crystalline form, while the work on the substance C free choice of artificial limb. At Roehampton it is is only now nearing completion, and cannot be not possible to secure the services of surgeons who are free from the restrictions of Government contracts. reported on at present. We are, Sir, yours faithfully, Substance A, as Dr. Lawrence rightly states, acts W. R. GROSSMITH, LTD. on rabbits according to their fasting blood-sugar levels. It increases the blood-sugar generally in those with a low level and decreases it in those with a high level. In over 20 cases of diabetics, treated so far in Warsaw clinics and elsewhere, it could be ascertained CYCLIC VOMITING. that the substance A acts like the old insulin. It is To the Editor of THE LANCET. too early, however, to state whether the new substance SiR,-In your issue of Dec. 4th appears an annopresents any disadvantage or advantage over insulin, tation under this heading, in which, after some but since it is free from the very toxic substances contained in commercial insulin the latter should be introductory remarks-not, I think, representing the case. In non-diabetics, on the contrary, the current pediatric opinion very accurately-we are substance A causes either no change in the blood-sugar introduced to the views of an American radiographer or appreciable increase. One exception was noted who has found in children suffering from this disorder a normal blood-sugar level, a high proportion of " ptosed stomach"" and of this was case with here ; Perhaps a more suitable text but with sugar in the urine one week before injection " elongated colon." of substance A. This interesting result suggests, for commentary might have been found in the valuable paper by Graham and Brown in the current number perhaps, that the substance A might be used with of the Archives of Disease in Childhood, in which success for diagnostic purposes, like the known sugar references will be found to much of the recent work tolerance-test, but it might be of more value to the on ketonuria, and ketogenesis-work which ketonæmia, than the latter. physician has a flood of light on the whole question, and shed One word more on the puzzling behaviour of substance A in diabetics and non-diabetics. My to which no reference is made in your article. All children-and quick, eager, excitable children, present explanation is that in non-diabetics there is lack of substance C (co-insulin), without which, with a high metabolic rate, more than othersperhaps, the substance A cannot act, or a superfluity respond to certain forms of stress, to infection, to of substance B (anti-insulin). In diabetics, on the starvation, to great exertion, to excitement, to contrary, there is too much of B (anti-insulin) and anaesthesia, and to a diet with a high proportion of sufficiency of C (co-insulin). I am conscious, however, fat and a low proportion of carbohydrate, by the that this interpretation may have to be modified. development of ketonasmia, with diminution in the Similar explanation can be put forward in Dr. alkaline reserveof the blood, and a transitory fall Lawrence’s interesting results (using ordinary insulin) in the blood-sugar. In practice it is apparent that these are precisely the factors which determine an on the blood-sugar increases in normal rabbits (which, I never encountered with good insulin). attack of so-called cyclical vomiting in susceptible personally, In such cases the effect of insulin might depend on children. Especially the factor of infection is of the ratio of substances A, B, and C in the preparation importance. The ordinary cold running through a used, and on the equilibrium of these three substances nursery will determine a simple rhinitis in the rest of the children, in the child so pre-disposed the in the animal itself. I should like to take this opportunity to offer, for underlying infection will be obscured by a typical sick attack." Yet it may be that a precisely similar purpose of investigation, small quantities of my crystalline substance A to the clinics in Great Britain. disturbance is produced by the stress of an examina"
I am, Sir, yours faithfully, CASIMIR FUNK. The Biochemical Department, State School of Hygiene, Chocimska 24, Warsaw, Poland, Dec. 4th, 1926.
THE SUPPLY OF ARTIFICIAL LIMBS. To the Editor of THE LANCET. agree with the opinion expressed by Mr. Muirhead Little in your issue of Dec. 4th as to the importance attaching to the inspection of artificial limbs by a surgeon who has had experience in such work, and we noted with interest his suggestion to establish a small limb-fitting centre in Central London. At present it is the practice in hospitals for the surgeon to inspect the various limbs supplied, and it is of great assistance to the limb-maker that the surgeon who performed the operation and knows the case should consult with him as to its special needs. The inspection of finished limbs by the surgeon affords the limb-maker opportunity of demonstrating the construction of the particular limb, and of receiving from the surgeon suggestions dictated by his knowledge of the individual circumstances of the amputation. Our experience is that orthopaedic surgeons are much more conversant with this subject now than in years gone by, and in cases supplied directly through hospitals or charitable institutions
SIR,—We
tion or by a long railway journey. In the administration of glucose, with or without insulin, we have in our hands a treatment which is on the whole strikingly effective. In prophylaxis some consideration, and it may be some modification, of the balance of fat and carbohydrate in the diet is very necessary, although not more necessary than the extirpation of any source of recurrent infection, whether, very rarely, in the appendix, or, very often, in the tonsils.. The response of different children to comparable infections is very various, and the metabolic component of the disturbance, and the ,nfective component, are often inextricably inter-
twined. Recent studies in metabolism have shown that he normal child possesses the power of drawing argely upon its own carbohydrate reserves to complete :.he oxidation of the fat in its diet, thus metabolising mixture very different from that ingested ; and it vould seem that in the child with cyclical vomiting his power is less evident. The tendency to " cyclical vomiting " is to be explained by some fault in carbolydrate metabolism, although we are still ignorant )f the precise nature of that fault. I think we may ,ake it that the length of the colon is of less significance. I am, Sir, yours faithfully, H. CHARLES CAMERON.
retaining the services of orthopaedic surgeons there is THE DISSOLUTION OF INSULIN. little danger of unsuitable limbs being supplied. It 2’0 the Editor of THE LANCET. would, however, undoubtedly be a boon to other SIR,—In view of Dr. R. D. Lawrence’s interesting civilian amputees if some plan existed by which the letter I am pleased to give to readers of THE LANCET patient could enjoy the combined skill of surgeon and limb-maker, although we doubt whether the number of a few more details of my recent work. Commercial insulin seems to be composed of at cases would warrant the establishment of a fitting least three substances-viz., the true pancreatic centre. At the Queen Mary’s Convalescent Auxiliary hormone A, the anti-insulin B, and co-insulin C. Of Hospital, Roehampton, the fitting is restricted to one these substances A and B have been obtained in or two firms, and the patient does not have a perfectly crystalline form, while the work on the substance C free choice of artificial limb. At Roehampton it is is only now nearing completion, and cannot be not possible to secure the services of surgeons who are free from the restrictions of Government contracts. reported on at present. We are, Sir, yours faithfully, Substance A, as Dr. Lawrence rightly states, acts W. R. GROSSMITH, LTD. on rabbits according to their fasting blood-sugar levels. It increases the blood-sugar generally in those with a low level and decreases it in those with a high level. In over 20 cases of diabetics, treated so far in Warsaw clinics and elsewhere, it could be ascertained CYCLIC VOMITING. that the substance A acts like the old insulin. It is To the Editor of THE LANCET. too early, however, to state whether the new substance SiR,-In your issue of Dec. 4th appears an annopresents any disadvantage or advantage over insulin, tation under this heading, in which, after some but since it is free from the very toxic substances contained in commercial insulin the latter should be introductory remarks-not, I think, representing the case. In non-diabetics, on the contrary, the current pediatric opinion very accurately-we are substance A causes either no change in the blood-sugar introduced to the views of an American radiographer or appreciable increase. One exception was noted who has found in children suffering from this disorder a normal blood-sugar level, a high proportion of " ptosed stomach"" and of this was case with here ; Perhaps a more suitable text but with sugar in the urine one week before injection " elongated colon." of substance A. This interesting result suggests, for commentary might have been found in the valuable paper by Graham and Brown in the current number perhaps, that the substance A might be used with of the Archives of Disease in Childhood, in which success for diagnostic purposes, like the known sugar references will be found to much of the recent work tolerance-test, but it might be of more value to the on ketonuria, and ketogenesis-work which ketonæmia, than the latter. physician has a flood of light on the whole question, and shed One word more on the puzzling behaviour of substance A in diabetics and non-diabetics. My to which no reference is made in your article. All children-and quick, eager, excitable children, present explanation is that in non-diabetics there is lack of substance C (co-insulin), without which, with a high metabolic rate, more than othersperhaps, the substance A cannot act, or a superfluity respond to certain forms of stress, to infection, to of substance B (anti-insulin). In diabetics, on the starvation, to great exertion, to excitement, to contrary, there is too much of B (anti-insulin) and anaesthesia, and to a diet with a high proportion of sufficiency of C (co-insulin). I am conscious, however, fat and a low proportion of carbohydrate, by the that this interpretation may have to be modified. development of ketonasmia, with diminution in the Similar explanation can be put forward in Dr. alkaline reserveof the blood, and a transitory fall Lawrence’s interesting results (using ordinary insulin) in the blood-sugar. In practice it is apparent that these are precisely the factors which determine an on the blood-sugar increases in normal rabbits (which, I never encountered with good insulin). attack of so-called cyclical vomiting in susceptible personally, In such cases the effect of insulin might depend on children. Especially the factor of infection is of the ratio of substances A, B, and C in the preparation importance. The ordinary cold running through a used, and on the equilibrium of these three substances nursery will determine a simple rhinitis in the rest of the children, in the child so pre-disposed the in the animal itself. I should like to take this opportunity to offer, for underlying infection will be obscured by a typical sick attack." Yet it may be that a precisely similar purpose of investigation, small quantities of my crystalline substance A to the clinics in Great Britain. disturbance is produced by the stress of an examina"
I am, Sir, yours faithfully, CASIMIR FUNK. The Biochemical Department, State School of Hygiene, Chocimska 24, Warsaw, Poland, Dec. 4th, 1926.
THE SUPPLY OF ARTIFICIAL LIMBS. To the Editor of THE LANCET. agree with the opinion expressed by Mr. Muirhead Little in your issue of Dec. 4th as to the importance attaching to the inspection of artificial limbs by a surgeon who has had experience in such work, and we noted with interest his suggestion to establish a small limb-fitting centre in Central London. At present it is the practice in hospitals for the surgeon to inspect the various limbs supplied, and it is of great assistance to the limb-maker that the surgeon who performed the operation and knows the case should consult with him as to its special needs. The inspection of finished limbs by the surgeon affords the limb-maker opportunity of demonstrating the construction of the particular limb, and of receiving from the surgeon suggestions dictated by his knowledge of the individual circumstances of the amputation. Our experience is that orthopaedic surgeons are much more conversant with this subject now than in years gone by, and in cases supplied directly through hospitals or charitable institutions
SIR,—We
tion or by a long railway journey. In the administration of glucose, with or without insulin, we have in our hands a treatment which is on the whole strikingly effective. In prophylaxis some consideration, and it may be some modification, of the balance of fat and carbohydrate in the diet is very necessary, although not more necessary than the extirpation of any source of recurrent infection, whether, very rarely, in the appendix, or, very often, in the tonsils.. The response of different children to comparable infections is very various, and the metabolic component of the disturbance, and the ,nfective component, are often inextricably inter-
twined. Recent studies in metabolism have shown that he normal child possesses the power of drawing argely upon its own carbohydrate reserves to complete :.he oxidation of the fat in its diet, thus metabolising mixture very different from that ingested ; and it vould seem that in the child with cyclical vomiting his power is less evident. The tendency to " cyclical vomiting " is to be explained by some fault in carbolydrate metabolism, although we are still ignorant )f the precise nature of that fault. I think we may ,ake it that the length of the colon is of less significance. I am, Sir, yours faithfully, H. CHARLES CAMERON.