BASAL METABOLISM IN GASTROINTESTINAL BLEEDING

173 In the

of alkalosis, intestinal obstruction, vomiting, and Addison’s disease which were examined there was considerable reduction of chlorides and elevation of urea in the C.S.F. In contrast to this the cases of nephritis showed elevation of both urea and chlorides, and the cases of tuberculous meningitis a reduction of chlorides without a gross elevation of the urea. In the first group of conditions it is known that there is a raised urea and decreased chloride content in the blood, but we feel that it should be cases

severe

that these changes are It has been suggested (Nicol and Lyall 1939) that the changes in the C.S.F. in alkalosis may be helpful in the differential diagnosis in some instances. We wish to endorse this view, and we consider its value is most outstanding in cases of coma, where a lesion of the central nervous system must be excluded and lumbar puncture performed, as in our two cases. It is also in such cases that an adequate history may be unobtainable and the possibility of alkalosis not considered. more

widely appreciated

reflected in the C.S.F.

Dodds (1939) with the Roth-Benedict apparatus. The accompanying table shows the B.M.R. and amplitude of breathing in twenty patients with hsematemesis and melaena admitted to the wards of the Radcliffe Infirmary. In fourteen of the cases bloodurea results are also available. The range of the twenty observations is from 29 to + 46, and the mean is z- 7, with a standard deviation of 17. The standard error of the mean is 3-8 ; hence the mean of the present series does not differ from the mean normal value-i.e., 0-by more than twice its standard error ; in other words, the B.M.R. in the cases investigated does not differ significantly from the normal. -

OBSERVATIONS

ON

PATIENTS

H1BMORRHAGE

WITH GASTRODUODENAL MELaeNA

AND

SUMMARY

of alkalosis are described illustrating the severe form which this syndrome may take and the clinical features which may help in the differential diagnosis. The C.S.F. shows a diminished chloride and an increased urea content, which may assist in

Two

cases

the diagnosis. We wish to thank Dr. J. Dick, medical super-

intendent, for permission to carry out this work, Dr. C. J. Polson for some of the pathological investigations, and Dr. H. G. Garland for valuable help and

criticism.

REFERENCES

Berger, E. H., and Binger, M. W. (1935) J. Amer. med. Ass. 104, 1383. Blum, L., Grabar, P., and Van Caulaert (1928) Pr. méd. 36, 1411.

Brown, G. E., Eusterman, G. B., Hartman, H. R., and Rowntree, L. G., (1923) Arch. intern. Med. 32, 425. Cooke, A. M. (1932) Quart. J. Med. 1, 527. Fowweather, F. S. (1925) J. Path. Bact. 28, 165. Hardt, L. L., and Rivers, A. B. (1923) Arch. intern. Med. 31, 171.

Harrison, G. A. (1930) Chemical Methods in Clinical Medicine, London.

Hurst, A. F., Houghton, L. W., Venables, J. F., and Lloyd, N. L. (1925) Guy’s Hosp. Rep. 75, 147. Linden, G. C., and Carmichael, E. A. (1928) Biochem. J. 22, 46. Macadam, W., and Gordon, J. (1922) Lancet, 2, 560. McCance, R. A., (1936) Ibid, 1, 643. - and Widdowson, E. M. (1937) Ibid, 2, 247. Nicol, B. M., and Lyall, A. (1939) Ibid, 1, 144. Rachmilewitz, M. (1934) Ibid, 1, 78. Ryle, J. A. (1936) Natural History of Disease, London, p. 345. Wildman, H. A. (1929) Arch. intern. Med. 43, 615.

BASAL METABOLISM IN GASTROINTESTINAL BLEEDING BY DOUGLAS A. K. BLACK, M.B. St. And., M.R.C.P. MEDICAL RESEARCH COUNCIL FELLOW

(From

the

Nuffield Department of Oxford)

Clinical

Medicine,

SEVERAL authors have expressed the opinion that there is an increased breakdown of body protein in association with the azotaemia of hsematemesis (Sanguinetti 1934, Su&i6 1935, Bookless 1938). Evidence has been obtained-loss of weight, creatinuria, and increase in the output of inorganic sulphur and phos-

phorus-suggesting

that such a process takes place 1940). Although it appeared unlikely on general grounds that there should be any corresponding increase of total metabolism, it was

(Black

and Leese

thought desirable to investigate the basal metabolic rate (B.M.R.) in cases of gastroduodenal bleeding. The method used was that described by Beaumont and

- Voe.—Case 15

was

complicated by chronic Bright’s disease. *

Per 100

c.cm.

The range of normal variation of the B.M.R. is from - 15 to + 15 per cent. (Beaumont and Dodds 1939). Fourteen of the twenty estimations thus fall within the normal range, and only three (cases 17, 19, and 20) are considerably above it. In view of the possibility that these three exceptions may represent merely a failure to attain strictly basal conditions in difficult circumstances, it may be concluded that increase of total metabolism is not of importance in causing the azotaemia of haematemesis. This is borne out by the absence of any correlation between the B.M.R. and the blood-urea where figures for both are available ; likewise, the B.M.R. appeared to bear no relation to the general condition of the patient. Henderson (1938) describes a close relationship in experimental animals between severity of haemorrhage and depth of breathing and claims that the volume of breathing is of value in prognosis. In our present series of cases, although we could not obtain any direct measure of the severity of the haemorrhage, the volume of breathing seemed to bear no relation to the level of blood-urea or to the patient’s general state. Measurement of the volume of breathing thus appears to be of no value in assessing the severity of

gastro-duodenal bleeding. CONCLUSION

In gastroduodenal haemorrhage there is no significant change in the B.M.R., and no relationship between the total metabolism and the degree of azotsemia. REFERENCES

Beaumont, G. E., and Dodds, E. C. (1939) Recent Advances in Medicine, London. Black, D., and Leese, A. (1940) Quart. J. Med. in the press. Bookless, A. S. (1938) Guy’s Hosp. Rep. 88, 22. Henderson, Y. (1938) Adventures in Respiration, London. Sanguinetti, L. V. (1934) Arch. argent. Enferm. Apar. dig. 9, 264. Sučić, D. (1935) Klin. Wschr. 14, 1316.