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ALKALOSIS.
1267
Clinical and
Laboratory Notes.
ALKALOSIS.
EDIN.,
IN THE LANCET of Oct. ] 6th, 1926, in an article Before and After Operation, by Sir Berkeley Moynihan, the subject of a,lkalosis is dealt with, and the treatment suggested is that of intravenous injection of normal saline, repeated if necessary, and the administration of dilute hydrochloric acid by the mouth. The line of treatment indicated by the heading of this article is one which I have been using for over a year now in all cases of intestinal obstruction with very successful results. It consists of the administration of 3 drachms of ammonium chloride in5 or 6 oz. of water per rectum just before operation ; and of the administration of 10 oz. of a 15 per cent. solution of sodium chloride intravenously as soon as the patient is put under the anesthetic. The stomach is, of course, always washed out previous to administration ofthe anesthetic. Even after prolonged intra-abdominal manipulations the patients usually go off the t’)ble with most satisfactory pulse, and at one’s visit next day a word that generally comes from their lips, on being asked how they feel, is on
"
uninterrupted. of normal saline and to find a Yer) useful condition of intussusception. The
glucose intravenously sphere in the allied
A NOTE ON THE
BACTERIAL CONTENT OF ICE-CREAM. BY E. G. RAWLINSON, M.D.
TORONTO, D.P.H. OXF.,
DIRECTOR OF PATHOLOGICAL LABORATORIES, THE ROYAL INSTITUTE OF PUBLIC HEALTH, LONDON.
THIRTY-FIVE samples of ice-cream, taken from various sources and exposed for sale in London, were examined in the hot period between July 16th and August 16th this year. The investigation was limited, and was undertaken only to obtain a general idea of bacterial contamination with reference to the number of organisms and the presence of coliform organisms, B. enteritidis sporogenes and streptococci. Bacterial Count.-The number of colonies agar at 37° C. for 24 hours :2 6 9 3
growing
samples showed under a million per c.cm. between 1 and 10 million "
"
"
"
"
10
"
5
10
50 100
over 1000
"
(2 of these
"
"
50 100
1000
million
on
per c.cm.
"
"
"
"
"
"
"
"
"
per c.cm.
uncountable in a one-millionth dilution.) Coliform Organisms.-The minimal amount showing the presence of acid and gas in litmus bile-salt lactose broth in 24 hours at 37’C. :4 samples showed acid and gas in 1 c.cm. 8 9 2 11 1
,
being large
amounts of brown offensive fluid). Operation revealed extensive abdominal tuberculosis, most marked in the ileo-caccal region, but with adhesions involving most of the neighbouring coils. The bowel already looked purplish, and the adhesive bands in this area were sloughing. A caecostomy was done, as the condition of the patient did not allow of anything further, and the outlook was not hopeful. Afterwards thencent’s condition improved considerably, and his cascost., acted, while his colon was relieved by enemata. Some 0 to 14 days after, the csecostomy refused to operate, gentle irrigation refused to bring anything away, and the patient began to complain of more pain. There was no vomiting, however, until after administering of5 grains of calomel without its having It was decided to reopen any effect via the caccostomy. the abdomen. After preliminary washing out of stomach, giving of ammonium chloride and concentrated sodium chloride, the abdomen was opened, and the collapsed small bowel was traced up to where another band strangled the bowel. Above this the small gut was dilated to the size of a dilated colon, was full of fluid, and quite inert. The bauds were cut, the fluid milked down the gut, and a jejunostomy performed. Sterile paraflin was passed over the raw surfaces left from breaking down of adhesions. Next day the patient was in wonderful condition, his only
use
seems
champion."
The rationale of the treatment appears to be that there is such a loss of HCI to the system by vomiting that the chlorides are seriously depleted, and require replenishing. This is supplied by both the salts used, but the ammonium may have some further beneficial action on the liver chemistry. As regards the use of so concentrated a solution of sodium chloride, it may be that its beneficent action is in part due to it being so concentrate i. and so preventing an exosmosis of plasma salts into the intestinal tract, much the same as hypertonic saline acts so beneficially in the treatment of cholera. The only drawbacks to this line of treatment are : (a) marked thirst, which, however, helps in flushing the system with plenty of fluid ; (b) sometimes anuria may be accompanied by severe diarrhea, but which are not of long duration ; (c) thrombosis of vein used for the injection. This does not seem to cause any trouble. Two recent cases, both of severe intestinal obstruction from abdominal tuberculosis, will serve to illustrate its use. rli 11 icul Recors. CASE I.-Male, aged 30, admitted to hospital with pain over appendix area, vomiting, and signs of obstruction. Treatment as above given. Stomach washed out (contents
pints
and eserine. Thereafter convalescence was uninterrupted. CASE 2 was that of a man, aged 25, admitted to hospital with signs of intestinal obstruction. His previous history was to the effect that he had undergone two abdominal operations for obstructive symptoms, when bands were found and enlarged glands noted. The last of these was three years ago, since when he had kept His face was very pinched, and he quite well. complained of a great deal of abdominal pain. The same routine was observed ; stomach washed out, am. chlor. and concentrated NaCI given. On opening the abdomen very extensive adhesions were found all over, particularly on the right side of the abdomen, where one band was kinking the bowel very tightly. It seemed hopeless to try to deal with all the adhesions and cover all the raw surfaces left. A jejunostomy was done, sterile paraffin passed all over the raw surfaces, and a drainagetube lodged suprapubically. The jejunostomy was to be used to wash out the upper tract four hourly with 0-5 per cent. sodii bicarb. solution. Next day the patient felt champion," and had a splendid pulse. It was noticed, however, that each time he was washed out or had a glucose feed with sodii bicarb. he was sick, bringing up bilious material. Thinking this might be some remains of the alkalosis, I advised the use of saline and glucose, after which there was no more sickness, and progress was
HONORARY ASSISTANT SURGEON. GREENBANK HOSPITAL, DARLINGTON.
"
jejunostomy drained
of dark brown fluid for days, and was used to feed him with 0’5 per cent. sodii bicarb. solution and 5 per cent. glucose. It was some days before the caecostomy acted again, and only after the continued use of pituitary
TREATMENT BY AMMONIUM CHLORIDE PER RECTUM AND CONCENTRATED SODIUM CHLORIDE INTRAVENOUSLY.
BY R. CHALMERS, M.D. ABERD., F.R.C.S.
The
complaint being of great thirst. away
were
"
001 c.cm. 0’0001 c.cm. 0’00001 c.cm.
"
0’000001 c.em.
"
,,
"
"
"
"
" "
"
sample showed no acid or gas in
1 c.cm.
or
less amount.
B. enteritidis sporogenes.-Minimal amount showing acid and torn clot in litmus milk. The ice-cream was heated to 80° C. for ten minutes and cultures grown anaerobically for three days at 37° C. :6 samples gave positive results in 1 c.cm. -
2
6 3 1 17
sample
H
"
"
"
"
"
"
"
"
,
"
"
"
"
samples (Dilutions were 26
not
" 0°1 C.f"ill. " 0’01 c.cm. " Ov01 c.cm. " 0 ’000 c.cin. z00001
1 C.Cl11.
taken higher than 1/JOO.OOO.)
Streptococci were found to be present in 1 e.en1-. of samples ; 9 of these were of a lonç:-chained variety. It should be stated that the samples were put up
for culture within an hour of collection, but were not transmitted in ice ; but even allowing for this, the figures appear to be excessive for a food fit to be consumed. The United States Department of Agriculture Bureau gives as an average a bacterial count of 38 millions per c.cm. in the summer months.
Clinical and
Laboratory Notes.
ALKALOSIS.
EDIN.,
IN THE LANCET of Oct. ] 6th, 1926, in an article Before and After Operation, by Sir Berkeley Moynihan, the subject of a,lkalosis is dealt with, and the treatment suggested is that of intravenous injection of normal saline, repeated if necessary, and the administration of dilute hydrochloric acid by the mouth. The line of treatment indicated by the heading of this article is one which I have been using for over a year now in all cases of intestinal obstruction with very successful results. It consists of the administration of 3 drachms of ammonium chloride in5 or 6 oz. of water per rectum just before operation ; and of the administration of 10 oz. of a 15 per cent. solution of sodium chloride intravenously as soon as the patient is put under the anesthetic. The stomach is, of course, always washed out previous to administration ofthe anesthetic. Even after prolonged intra-abdominal manipulations the patients usually go off the t’)ble with most satisfactory pulse, and at one’s visit next day a word that generally comes from their lips, on being asked how they feel, is on
"
uninterrupted. of normal saline and to find a Yer) useful condition of intussusception. The
glucose intravenously sphere in the allied
A NOTE ON THE
BACTERIAL CONTENT OF ICE-CREAM. BY E. G. RAWLINSON, M.D.
TORONTO, D.P.H. OXF.,
DIRECTOR OF PATHOLOGICAL LABORATORIES, THE ROYAL INSTITUTE OF PUBLIC HEALTH, LONDON.
THIRTY-FIVE samples of ice-cream, taken from various sources and exposed for sale in London, were examined in the hot period between July 16th and August 16th this year. The investigation was limited, and was undertaken only to obtain a general idea of bacterial contamination with reference to the number of organisms and the presence of coliform organisms, B. enteritidis sporogenes and streptococci. Bacterial Count.-The number of colonies agar at 37° C. for 24 hours :2 6 9 3
growing
samples showed under a million per c.cm. between 1 and 10 million "
"
"
"
"
10
"
5
10
50 100
over 1000
"
(2 of these
"
"
50 100
1000
million
on
per c.cm.
"
"
"
"
"
"
"
"
"
per c.cm.
uncountable in a one-millionth dilution.) Coliform Organisms.-The minimal amount showing the presence of acid and gas in litmus bile-salt lactose broth in 24 hours at 37’C. :4 samples showed acid and gas in 1 c.cm. 8 9 2 11 1
,
being large
amounts of brown offensive fluid). Operation revealed extensive abdominal tuberculosis, most marked in the ileo-caccal region, but with adhesions involving most of the neighbouring coils. The bowel already looked purplish, and the adhesive bands in this area were sloughing. A caecostomy was done, as the condition of the patient did not allow of anything further, and the outlook was not hopeful. Afterwards thencent’s condition improved considerably, and his cascost., acted, while his colon was relieved by enemata. Some 0 to 14 days after, the csecostomy refused to operate, gentle irrigation refused to bring anything away, and the patient began to complain of more pain. There was no vomiting, however, until after administering of5 grains of calomel without its having It was decided to reopen any effect via the caccostomy. the abdomen. After preliminary washing out of stomach, giving of ammonium chloride and concentrated sodium chloride, the abdomen was opened, and the collapsed small bowel was traced up to where another band strangled the bowel. Above this the small gut was dilated to the size of a dilated colon, was full of fluid, and quite inert. The bauds were cut, the fluid milked down the gut, and a jejunostomy performed. Sterile paraflin was passed over the raw surfaces left from breaking down of adhesions. Next day the patient was in wonderful condition, his only
use
seems
champion."
The rationale of the treatment appears to be that there is such a loss of HCI to the system by vomiting that the chlorides are seriously depleted, and require replenishing. This is supplied by both the salts used, but the ammonium may have some further beneficial action on the liver chemistry. As regards the use of so concentrated a solution of sodium chloride, it may be that its beneficent action is in part due to it being so concentrate i. and so preventing an exosmosis of plasma salts into the intestinal tract, much the same as hypertonic saline acts so beneficially in the treatment of cholera. The only drawbacks to this line of treatment are : (a) marked thirst, which, however, helps in flushing the system with plenty of fluid ; (b) sometimes anuria may be accompanied by severe diarrhea, but which are not of long duration ; (c) thrombosis of vein used for the injection. This does not seem to cause any trouble. Two recent cases, both of severe intestinal obstruction from abdominal tuberculosis, will serve to illustrate its use. rli 11 icul Recors. CASE I.-Male, aged 30, admitted to hospital with pain over appendix area, vomiting, and signs of obstruction. Treatment as above given. Stomach washed out (contents
pints
and eserine. Thereafter convalescence was uninterrupted. CASE 2 was that of a man, aged 25, admitted to hospital with signs of intestinal obstruction. His previous history was to the effect that he had undergone two abdominal operations for obstructive symptoms, when bands were found and enlarged glands noted. The last of these was three years ago, since when he had kept His face was very pinched, and he quite well. complained of a great deal of abdominal pain. The same routine was observed ; stomach washed out, am. chlor. and concentrated NaCI given. On opening the abdomen very extensive adhesions were found all over, particularly on the right side of the abdomen, where one band was kinking the bowel very tightly. It seemed hopeless to try to deal with all the adhesions and cover all the raw surfaces left. A jejunostomy was done, sterile paraffin passed all over the raw surfaces, and a drainagetube lodged suprapubically. The jejunostomy was to be used to wash out the upper tract four hourly with 0-5 per cent. sodii bicarb. solution. Next day the patient felt champion," and had a splendid pulse. It was noticed, however, that each time he was washed out or had a glucose feed with sodii bicarb. he was sick, bringing up bilious material. Thinking this might be some remains of the alkalosis, I advised the use of saline and glucose, after which there was no more sickness, and progress was
HONORARY ASSISTANT SURGEON. GREENBANK HOSPITAL, DARLINGTON.
"
jejunostomy drained
of dark brown fluid for days, and was used to feed him with 0’5 per cent. sodii bicarb. solution and 5 per cent. glucose. It was some days before the caecostomy acted again, and only after the continued use of pituitary
TREATMENT BY AMMONIUM CHLORIDE PER RECTUM AND CONCENTRATED SODIUM CHLORIDE INTRAVENOUSLY.
BY R. CHALMERS, M.D. ABERD., F.R.C.S.
The
complaint being of great thirst. away
were
"
001 c.cm. 0’0001 c.cm. 0’00001 c.cm.
"
0’000001 c.em.
"
,,
"
"
"
"
" "
"
sample showed no acid or gas in
1 c.cm.
or
less amount.
B. enteritidis sporogenes.-Minimal amount showing acid and torn clot in litmus milk. The ice-cream was heated to 80° C. for ten minutes and cultures grown anaerobically for three days at 37° C. :6 samples gave positive results in 1 c.cm. -
2
6 3 1 17
sample
H
"
"
"
"
"
"
"
"
,
"
"
"
"
samples (Dilutions were 26
not
" 0°1 C.f"ill. " 0’01 c.cm. " Ov01 c.cm. " 0 ’000 c.cin. z00001
1 C.Cl11.
taken higher than 1/JOO.OOO.)
Streptococci were found to be present in 1 e.en1-. of samples ; 9 of these were of a lonç:-chained variety. It should be stated that the samples were put up
for culture within an hour of collection, but were not transmitted in ice ; but even allowing for this, the figures appear to be excessive for a food fit to be consumed. The United States Department of Agriculture Bureau gives as an average a bacterial count of 38 millions per c.cm. in the summer months.