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BLOOD IN THE STOOLS
482 and hsemorrhagic tendencies. The in the two series were identical and among mortality-rates premature infants there were 7 deaths in each group out of 45 control and 48 vitamin-K treated infants respectively. It is clear that enough vitamin K was given, for the usual results on the blood prothrombin The Chicago paediatricians say that the were obtained. for these results must lie in two directions. explanation " Either we do not know what haemorrhagic disease is, or there is a marked difference in our newborn babies as compared to other localities." The latter possibility raises questions of maternal diet, seasonal incidence and other problems which can be summed up in the possibility that careful antenatal care may play a part in preventing haemorrhages in the newborn. This point is capable of statistical study and could be quickly settled. The former possibility is, of course, the crux of the matter. It is palpably absurd to lump all hsemorrhagic manifestations of the newborn together and pretend that this is a " haemorrhagic disease " due to prothrombin deficiency and preventable and curable by giving vitamin
thrombin
level
tion of citrated blood. After a single large dose of blood the stools gave a positive test for as long as fourteen days ; all the patients were of course kept on a meat free, vegetable-free diet during the tests and had a preliminary negative test for occult blood in the stools. From these observations it seems that a tarry stool does not necessarily indicate a severe haemorrhage into the digestive tract and that the persistence of tarry stools or occult blood does not necessarily indicate the continuation of such haemorrhage. SURGERY
AT PEARL
HARBOUR
ON Dec. 3 Dr. J. J. Moorhead of New York arrived in Honolulu at the invitation of the local medical society to deliver a series of lectures on the principles of traumatic surgery. Four days later, now acting colonel in the Army Medical Corps, he found himself supervising the application of these principles in treating the victims of the attack on Pearl Harbour. He describesthe inevitable confusion caused by the influx of a large number of casualties ; but soon eight operating teams were on duty K. Whatever the facts as regard adult prothrombin and worked continuously for Ihours, after which regular 6-hour shifts were organised. The numerous and varied levels and haemorrhages may be the problem in the casualties consisted largely of the multiple lacerated newborn is not so simple, and the Chicago workers have done well to introduce the necessary element of scientific wounds and compound fractures which have made up doubt into what was threatening to become almost a the bulk of air-raid casualties here, and treatment was on lines. Initial morphine and blood- or plasmasimplified romance, with disappointment round the familiar were followed by cleansing, moderate extransfusion K corner for those who pinned their faith to vitamin local cision, sulphathiazole, and, when possible, delayed to the of other
factors.
neglect
BLOOD
IN
THE
STOOLS
IN those medical emergencies characterised by bleeding into the alimentary tract it is important for the clinician to know how much significance can be attached to the appearance of blood in the stools. L. Schiff, R. J. Stevens, N. Shapiro and S. Goodman have tried to clarify matters by giving citrated blood by mouth. Their experiments fall into three groups. In the first they determined the amount of blood necessary to produce a tarry stooldefined as " a glistening stool having the same black colour as found on a standard paint colour chart." Citrated venous blood, two to three weeks old, was mixed with soda-water (100-200 c.cm.) to disguise the taste and given .by mouth to three normals and fifteen ward patients. A normal diet was allowed and drugs known to discolour the stools were prohibited. The amount of blood was varied in quantity and it was found that at least 100 c.cm. of blood was necessary to produce a tarry stool-or to put it the other way round from the practical standpoint-a tarry stool may result from as little as 100 c.cm. of blood. The second experiment was concerned with .the time of appearance of bloody or tarry stools after intragastric administration of citrated blood. The blood was three weeks old, from a blood bank, and was given at room temperature by stomach-tube in quantities of 1000-2000 c.cm. The smaller quantities were allowed to flow in by gravity during a period of thirty to sixty minutes. The large amounts were given in divided doses of 700, 700 and 600 c.cm. at four-hourly intervals. An injection of codeine sulphate, gr. 1, and atropine sulphate, gr. 50,was given hypodermically before the blood to prevent too rapid passage through the alimentary tract. Despite this measure, blood appeared in the stools within four hours and a patient’s stools might be entirely bloody and were tarry after intragastric administration. Neither the appearance-bloody or tarry-nor the number of bloody or tarry stools was directly related to the quantity of blood given. None of the subjects vomited the blood. Bloody stools may be passed for as long as three days and tarry stools for as long as four days after a single draught of blood. Thirdly, experiments were. performed to determine the duration of a positive test for occult blood in the stools after oral or intragastric administra1. Amer. J. med. Sci. 1942,
203, 409.
primary suture ; primary suture was never employed and closed plaster was applied only for minor compound injuries. Moorhead found very useful for the localisation of metallic foreign bodies the radio-frequency probe which has been used by the Germans in this war and described in these columns 2 ; this is an electromagnetic induction apparatus which registers the surface-position and depth of the fragment and gives audible warning when it is approached by a metal probe. In one case, with a bullet lodged in the spinal canal, this instrument provided the only means of successful extraction. Another dramatic procedure was the removal of intrathoracic fragments under the radiographic screen by means of a long clamp introduced through a stab intercostal wound ; this, perhaps, will not be universally approved though it was found to give gratifying results. Summing up the lessons learned at Pearl Harbour, Moorhead emphasises the low operative mortality of 3’8%, the almost complete prevention of suppuration and, the absence of deaths from gas-gangrene, and the excellence of the late results. All of these were in striking contrast to experience in the first World War, but circumstances were particularly favourable. The wounded were received within 6 hours, preliminary treatment for shock was available and climatic conditions -were excellent; the standard of surgical skill was high and aftercare was adequate and continuous. The results demonstrate the value of a careful and preconceived plan of treatment. As part of the Ministry of Health’s policy to make the Central Council for Health Education the sole body responsible for popular health education in England and Wales, last week the- Central Council took over educational work for the prevention and treatment of venereal diseases hitherto undertaken for local authorities by the British Social Hygiene Council. The BSHC will continue as a voluntary organisation and carry on with its colonial and international work on the control of venereal disease and the social implications of these diseases in Great Britain. It will concentrate on problems of social biology, including preparation for marriage, the adjustment of personal problems and the application of present knowledge of the biological sciences to social problems of today, particularly those related to the war effort. The BSHC may be addressed at Tavistock House South, Tavistock Square, London, W.C.I. 1. Moorhead, J. J. J. Amer. med. Ass. 1942, 118, 712. 2. See Lancet, 1941, i, 699 ; Farmer, F. T. and Osborn, S. B. Ibid, 1941, ii, 517.
thrombin
level
tion of citrated blood. After a single large dose of blood the stools gave a positive test for as long as fourteen days ; all the patients were of course kept on a meat free, vegetable-free diet during the tests and had a preliminary negative test for occult blood in the stools. From these observations it seems that a tarry stool does not necessarily indicate a severe haemorrhage into the digestive tract and that the persistence of tarry stools or occult blood does not necessarily indicate the continuation of such haemorrhage. SURGERY
AT PEARL
HARBOUR
ON Dec. 3 Dr. J. J. Moorhead of New York arrived in Honolulu at the invitation of the local medical society to deliver a series of lectures on the principles of traumatic surgery. Four days later, now acting colonel in the Army Medical Corps, he found himself supervising the application of these principles in treating the victims of the attack on Pearl Harbour. He describesthe inevitable confusion caused by the influx of a large number of casualties ; but soon eight operating teams were on duty K. Whatever the facts as regard adult prothrombin and worked continuously for Ihours, after which regular 6-hour shifts were organised. The numerous and varied levels and haemorrhages may be the problem in the casualties consisted largely of the multiple lacerated newborn is not so simple, and the Chicago workers have done well to introduce the necessary element of scientific wounds and compound fractures which have made up doubt into what was threatening to become almost a the bulk of air-raid casualties here, and treatment was on lines. Initial morphine and blood- or plasmasimplified romance, with disappointment round the familiar were followed by cleansing, moderate extransfusion K corner for those who pinned their faith to vitamin local cision, sulphathiazole, and, when possible, delayed to the of other
factors.
neglect
BLOOD
IN
THE
STOOLS
IN those medical emergencies characterised by bleeding into the alimentary tract it is important for the clinician to know how much significance can be attached to the appearance of blood in the stools. L. Schiff, R. J. Stevens, N. Shapiro and S. Goodman have tried to clarify matters by giving citrated blood by mouth. Their experiments fall into three groups. In the first they determined the amount of blood necessary to produce a tarry stooldefined as " a glistening stool having the same black colour as found on a standard paint colour chart." Citrated venous blood, two to three weeks old, was mixed with soda-water (100-200 c.cm.) to disguise the taste and given .by mouth to three normals and fifteen ward patients. A normal diet was allowed and drugs known to discolour the stools were prohibited. The amount of blood was varied in quantity and it was found that at least 100 c.cm. of blood was necessary to produce a tarry stool-or to put it the other way round from the practical standpoint-a tarry stool may result from as little as 100 c.cm. of blood. The second experiment was concerned with .the time of appearance of bloody or tarry stools after intragastric administration of citrated blood. The blood was three weeks old, from a blood bank, and was given at room temperature by stomach-tube in quantities of 1000-2000 c.cm. The smaller quantities were allowed to flow in by gravity during a period of thirty to sixty minutes. The large amounts were given in divided doses of 700, 700 and 600 c.cm. at four-hourly intervals. An injection of codeine sulphate, gr. 1, and atropine sulphate, gr. 50,was given hypodermically before the blood to prevent too rapid passage through the alimentary tract. Despite this measure, blood appeared in the stools within four hours and a patient’s stools might be entirely bloody and were tarry after intragastric administration. Neither the appearance-bloody or tarry-nor the number of bloody or tarry stools was directly related to the quantity of blood given. None of the subjects vomited the blood. Bloody stools may be passed for as long as three days and tarry stools for as long as four days after a single draught of blood. Thirdly, experiments were. performed to determine the duration of a positive test for occult blood in the stools after oral or intragastric administra1. Amer. J. med. Sci. 1942,
203, 409.
primary suture ; primary suture was never employed and closed plaster was applied only for minor compound injuries. Moorhead found very useful for the localisation of metallic foreign bodies the radio-frequency probe which has been used by the Germans in this war and described in these columns 2 ; this is an electromagnetic induction apparatus which registers the surface-position and depth of the fragment and gives audible warning when it is approached by a metal probe. In one case, with a bullet lodged in the spinal canal, this instrument provided the only means of successful extraction. Another dramatic procedure was the removal of intrathoracic fragments under the radiographic screen by means of a long clamp introduced through a stab intercostal wound ; this, perhaps, will not be universally approved though it was found to give gratifying results. Summing up the lessons learned at Pearl Harbour, Moorhead emphasises the low operative mortality of 3’8%, the almost complete prevention of suppuration and, the absence of deaths from gas-gangrene, and the excellence of the late results. All of these were in striking contrast to experience in the first World War, but circumstances were particularly favourable. The wounded were received within 6 hours, preliminary treatment for shock was available and climatic conditions -were excellent; the standard of surgical skill was high and aftercare was adequate and continuous. The results demonstrate the value of a careful and preconceived plan of treatment. As part of the Ministry of Health’s policy to make the Central Council for Health Education the sole body responsible for popular health education in England and Wales, last week the- Central Council took over educational work for the prevention and treatment of venereal diseases hitherto undertaken for local authorities by the British Social Hygiene Council. The BSHC will continue as a voluntary organisation and carry on with its colonial and international work on the control of venereal disease and the social implications of these diseases in Great Britain. It will concentrate on problems of social biology, including preparation for marriage, the adjustment of personal problems and the application of present knowledge of the biological sciences to social problems of today, particularly those related to the war effort. The BSHC may be addressed at Tavistock House South, Tavistock Square, London, W.C.I. 1. Moorhead, J. J. J. Amer. med. Ass. 1942, 118, 712. 2. See Lancet, 1941, i, 699 ; Farmer, F. T. and Osborn, S. B. Ibid, 1941, ii, 517.