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THE HEART AND CIRCULATION IN BERI-BERI.
478 many for gastric ulcer. It is essential to differentiate, removal of that support affects the weaker-waller for in many respects the two diseases are very unlike. right ventricle at an earlier stage than the left. I have The type of patient is not the same, gastric ulcer suggested the formula F = (P + 1) (T + 8) where makes the patient much more ill as a rule, and F== fibrillation, P—pressure, I=impulses, T =tone, duodenal ulcer is virtually never the precursor of and S =support ; from which it is easy to see that malignant disease. It is a debatable point as to if tone or support or both be diminished the tendency how often carcinoma becomes grafted on to gastric to fibrillation is increased. In beri-beri effusion occurs ulcer, but I think most surgeons allow that it happens into the serous cavities, the general feebleness of the sufficiently often to cause the possibility of any such circulation implies that tone is less, consequently change to pass through their minds on most of the heart failure sets in. Prof. Wenckebach suggests occasions on which they deal with a gastric ulcer. the existence of a law of circulatory correlation The difference between the two types of ulcer (or I between the right and left heart, working along simple perhaps one should say the types of patient) has a mechanical lines. Does my formula help him in his vital bearing on the statistics of anastomotic ulcer contention ? I am, Sir, yours faithfully, following gastrectomy. I have seen three cases G. ARBOUR STEPHENS, where such an ulcer had formed after partial gastrecConsulting Cardiologist, King Edward VII. Welsh tomy had been done for jejunal ulcer in which gastroNational Memorial. enterostomy had been done previously for duodenal 1928. August Swansea, 18th, I have Sir ulcer; Berkeley Moynihan’s permission to say that he has had 12 such cases sent to him, and that he has never seen an anastomotic ulcer
develop after
a primary gastrectomy for gastric ulcer. Mr. Lake’s explanation, that too little of the stomach was removed (that is to say, not all of the acid secreting part) does not apply to these cases. Because of the difficulty of dealing directly with ulcers on the posterior surface of the duodenum, eroding the pancreas and causing marked deformity, I should regard these as the ulcers to be treated by gastrectomy, if this operation were ever necessary for duodenal ulcer; but gastro-enterostomy is very successful in these cases and the mortality is less than 1 per cent. I venture to say that in a series of this type gastrectomy would show a very much bigger mortality, and I presume this is the kind of ulcer Mr. Pannett has in mind when he finds it necessary to insert in his book on gastro-duodenal ulceration some paragraphs dealing with injury to the bile and pancreatic ducts as a complication which is observed in a certain percentage of cases of resection. It is a great mistake to think that having performed the operation of gastro-enterostomy the business is finished. It is essential to deal with the ulcer at the time, and to treat the patient medically for I long afterwards. I would suggest that the failure to take these two points into consideration in compiling statistics goes far to explain the high figures of ’, unsatisfactory results sometimes given. This does I not condemn gastro-enterostomy, or show the necessity to substitute gastrectomy ; it is a reflection ’, on the vision of the surgeon, for after all there is, or may be, still an ulcer present, and the operation only goes part of the way in promoting the patient’s
itself
complete
recovery.
could show that gastrohigh percentage of unsatisfactory results which he quotes, in spite of a full measure of complementary treatment before, at, and after the operation, he would convince his readers that there were sound grounds for advocating gastrectomy for duodenal ulcer-even though it is followed by a higher mortality, and carries with it the risk of I
think if Mr.
enterostomy
Lake
gave the
anastomotic ulceration, a risk which may prove to be as great as that after gastro-enterostomy, if no
mOT’P.-I
am.
Sir.
vours
faithflll1V.
E. R. FLINT. F.R.C.S. Eng. "
Leeds, August 15th, 1928.
THE HEART AND CIRCULATION IN BERI-BERI. To the Editor of THE LANCET. SIR,-May I refer Dr. Sutherland to the Dublin Journal of Medical Science for October, 1916, in which I draw attention to the negative pressure existing in the pericardium of a healthy person, and its tendency to disappear from the pericardia of persons in illhealth, especially those with serous effusion in the large cavities. This negative pressure results in a suction action whereby’the pericardial fluid is kept at an equal thickness all over the surface of the heart and acts as a support to the working organ. A
THE VITAMIN A CONTENT OF COD-LIVER
OILS. To the Editor
of
THE LANCET.
SiR,-In your issue of June 30th (p. 1353) Prof. J. C. Drummond attempts to counter statements made in an article published in the Anglo-Norwegian Trade Journal for May, 1928, which is based upon information which I have given the editor of that journal. Drummond’s reply does not touch upon the crux of the matter, and is therefore unsatisfactory. As previous articles regarding this matter have appeared some years ago, a short resume is necessary. 1. In 1924 Prof. Drummond (University College, London), jointly with Dr. S. S. Zilva (the Lister Institute, London) and Dr. Graham (The Fisheries Laboratory, Lowestoft), published in the Biochemical Journal (1924, XVIII., 178) a paper entitled: The Relation of the Vitamin A Potency of the Liver Oil to the Sexual Condition and Age of the Cod. In this very searching work they particularly treated the question whether the spawning of the cod had any influence on the vitamin content of the oil. Repeatedly, and in a most definite way, it is stated in the article referred to that no such influence could be demonstrated. For example: regarding the results of the four series of tests of cod from Flamborough and Scarborough during the months of January to June, it is stated that " even the liver oils from spent cod in March fish, which must have spawned just before being caught, and which had no time to recuperate, did not deviate in potency from the oils of fish before spawning, and several months after spawning and consequently after recuperation." The paper ends up with the following summary : " The sexual condition and age of the cod do not influence the vitamin A potency of the liver oil." In 1924- I myself carried out similar investigations, and came to the same conclusion, but in view of the paper in the Biochemical Journal, I considered any publication of my findings superfluous. 2. In 1925 Prof. Drummond published in THE LANCET (Sept. 26th, p. 679) a paper in which, without producing any fresh data, he says, with regard to oils produced in the important fishing district of Lofoten (Norway), that during spawning the oil becomes poor in vitamins and contains only one-tenth to one-fifth of the vitamin potency of that of oil from other places (Finmarken and Newfoundland), where the fisheries do not take place during the
spawning period. The reason apparently being that, when the fish " are practically starving during the spawning period, and are at the same time transferring much fat and vitamin to the reproductive cells, the livers yield an’ almost white oil of relatively low potency." This is exactly opposite to the findings of Prof. Drummond and his collaborators in 1924: about the fish in this condition it is here said that " the relative potency of the residual liver oil is however, not effected."
develop after
a primary gastrectomy for gastric ulcer. Mr. Lake’s explanation, that too little of the stomach was removed (that is to say, not all of the acid secreting part) does not apply to these cases. Because of the difficulty of dealing directly with ulcers on the posterior surface of the duodenum, eroding the pancreas and causing marked deformity, I should regard these as the ulcers to be treated by gastrectomy, if this operation were ever necessary for duodenal ulcer; but gastro-enterostomy is very successful in these cases and the mortality is less than 1 per cent. I venture to say that in a series of this type gastrectomy would show a very much bigger mortality, and I presume this is the kind of ulcer Mr. Pannett has in mind when he finds it necessary to insert in his book on gastro-duodenal ulceration some paragraphs dealing with injury to the bile and pancreatic ducts as a complication which is observed in a certain percentage of cases of resection. It is a great mistake to think that having performed the operation of gastro-enterostomy the business is finished. It is essential to deal with the ulcer at the time, and to treat the patient medically for I long afterwards. I would suggest that the failure to take these two points into consideration in compiling statistics goes far to explain the high figures of ’, unsatisfactory results sometimes given. This does I not condemn gastro-enterostomy, or show the necessity to substitute gastrectomy ; it is a reflection ’, on the vision of the surgeon, for after all there is, or may be, still an ulcer present, and the operation only goes part of the way in promoting the patient’s
itself
complete
recovery.
could show that gastrohigh percentage of unsatisfactory results which he quotes, in spite of a full measure of complementary treatment before, at, and after the operation, he would convince his readers that there were sound grounds for advocating gastrectomy for duodenal ulcer-even though it is followed by a higher mortality, and carries with it the risk of I
think if Mr.
enterostomy
Lake
gave the
anastomotic ulceration, a risk which may prove to be as great as that after gastro-enterostomy, if no
mOT’P.-I
am.
Sir.
vours
faithflll1V.
E. R. FLINT. F.R.C.S. Eng. "
Leeds, August 15th, 1928.
THE HEART AND CIRCULATION IN BERI-BERI. To the Editor of THE LANCET. SIR,-May I refer Dr. Sutherland to the Dublin Journal of Medical Science for October, 1916, in which I draw attention to the negative pressure existing in the pericardium of a healthy person, and its tendency to disappear from the pericardia of persons in illhealth, especially those with serous effusion in the large cavities. This negative pressure results in a suction action whereby’the pericardial fluid is kept at an equal thickness all over the surface of the heart and acts as a support to the working organ. A
THE VITAMIN A CONTENT OF COD-LIVER
OILS. To the Editor
of
THE LANCET.
SiR,-In your issue of June 30th (p. 1353) Prof. J. C. Drummond attempts to counter statements made in an article published in the Anglo-Norwegian Trade Journal for May, 1928, which is based upon information which I have given the editor of that journal. Drummond’s reply does not touch upon the crux of the matter, and is therefore unsatisfactory. As previous articles regarding this matter have appeared some years ago, a short resume is necessary. 1. In 1924 Prof. Drummond (University College, London), jointly with Dr. S. S. Zilva (the Lister Institute, London) and Dr. Graham (The Fisheries Laboratory, Lowestoft), published in the Biochemical Journal (1924, XVIII., 178) a paper entitled: The Relation of the Vitamin A Potency of the Liver Oil to the Sexual Condition and Age of the Cod. In this very searching work they particularly treated the question whether the spawning of the cod had any influence on the vitamin content of the oil. Repeatedly, and in a most definite way, it is stated in the article referred to that no such influence could be demonstrated. For example: regarding the results of the four series of tests of cod from Flamborough and Scarborough during the months of January to June, it is stated that " even the liver oils from spent cod in March fish, which must have spawned just before being caught, and which had no time to recuperate, did not deviate in potency from the oils of fish before spawning, and several months after spawning and consequently after recuperation." The paper ends up with the following summary : " The sexual condition and age of the cod do not influence the vitamin A potency of the liver oil." In 1924- I myself carried out similar investigations, and came to the same conclusion, but in view of the paper in the Biochemical Journal, I considered any publication of my findings superfluous. 2. In 1925 Prof. Drummond published in THE LANCET (Sept. 26th, p. 679) a paper in which, without producing any fresh data, he says, with regard to oils produced in the important fishing district of Lofoten (Norway), that during spawning the oil becomes poor in vitamins and contains only one-tenth to one-fifth of the vitamin potency of that of oil from other places (Finmarken and Newfoundland), where the fisheries do not take place during the
spawning period. The reason apparently being that, when the fish " are practically starving during the spawning period, and are at the same time transferring much fat and vitamin to the reproductive cells, the livers yield an’ almost white oil of relatively low potency." This is exactly opposite to the findings of Prof. Drummond and his collaborators in 1924: about the fish in this condition it is here said that " the relative potency of the residual liver oil is however, not effected."