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CARDIAC OUTPUT AND RENAL BLOOD-FLOW IN SEVERE DEHYDRATION
644 THE FRONTIERS OF MEDICINE have read with interest Prof. C. H. Stuart-Harris’ SiR,—I article of Aug. 30: like those of the celebrated egg, parts of it are excellent; but I resent very deeply his statement " When I was a student, it was common to feel that patients were admitted to the medical wards to lie and rot. The great watch-word wasmasterly inactivity’ ... " (Dr. Stuart-Harris qualified as recently as 1931.) I should like to ask him (a) whether his insult is intended only for the physicians of the hospital where he was a student or for British physicians in general, and (b) whether he thinks that his opinion is widely shared by the large numbers of whole-time professors and lecturers who are now mainly responsible for the training of young
far been possible to discover whether the due to the presence of an activator or the disappearance of a serum inhibitor: any such inhibitor, which disappears at a temperature of 56°C maintained for 30 min, may be represented by a heat-labile fraction of the complement (Cl or Cl) which is destroved at that temnerature. Institute of Medical Pathology, V. ROSSI. University of Genoa. It has not
INTRAGASTRIC INFUSION
SIR,-In 1956,
ROBERT MARSHALL. ATTEMPTED SUICIDE
SIR,-It is impossible for authors to defend themselves against an anonymous review, even if they feel that their work has not received a fair appraisal. They have, however, the right to protest against misquotations. I am referring to the review (Sept. 6) of the book Attempted Suicide. In this and other books the term " suicidal act’-’ has been used for both suicide and attempted suicide. According to your review it was used only for the latter, which is quoted as having been regarded by the authors as not self-destructive. No such nonsense was asserted in the book. On the contrary, it was made quite clear that every suicidal act aimed at self-destruction but that the suicidal attempt could not be fully understood if this motivation alone was taken into consideration. E. STENGEL
* * * We much regret that our brief summary of the views of Professor Stengel and Miss Cook should have misrepresented them. Most authors will sympathise with him about the difficulty of defence against criticism in review; but this is no greater when the review is editorial than when it is personal. Our reviews, like our annotations and leaders, can be challenged.-ED. L. EFFECT OF INACTIVATED SERUM ON COLD AGGLUTININS SIR,-From the studies of Boorman and Dodd1 we learn that human serum can enhance the activity of
immune isoantibodies when it is used as a diluent instead of saline. Also in other immune systems (immune serum anti-sheep-red-cells or in Rose’s test for rheumatoid arthritis) human serum reveals this property. I have investigated whether normal human serum retains this property also in the titration of autoantibodies, and I chose the cold agglutinins as more readily titrable. serum
is used instead of saline, the titre of the cold
agglutinins increases but little; while if a previously inactivated (at 56°C for 30 min.) serum is used, there is a huge increase in the titre (from 1 : 4000 to 1 : 16 million in one case, and from 1 : 1000 to 1 : 4000 in another). The use of albumin or human gamma-globulin instead of serum does not bring about the phenomenon. Serums devoid of properdin have given similar results, as have also normal serums that have not been inactivated but kept at -20°C for months. Not all human serums show this considerable activation of the autoantibody titre: some, in fact, are incapable of producing it, while others increase the titre only slightly. one to two
1. Boorman, K. E., Dodd, B. E. J. Path. Bact. 1947,
59, 95.
you
were
good enough
to
publish
a
short communication about intragastric infusion in infants with acute dyspepsia.
doctors.
If fresh
so
phenomenon is
We have now used this method 140 times in infants, mainly for acute gastroenteritis. We gave physiological saline, Ringer’s or Darrow’s solutions, and 5 % glucose solution, the amount and proportions being the same as for parenteral infusions. Sometimes we added plasma substitutes. Sometimes plasma was given intravenously. In milder cases gastric infusion was combined with feeding by mouth or through the tube. We used polyethylene and rubber tubes, as thin as possible, passed through the nose. We have not seen any serious complications, even after leaving the tube in for several days. The effect on vomiting was striking. In severe gastroenteritis the rehydratation was often slower than by the intravenous route, but sometimes the result was almost equally good. In toxic gastroenteritis gastric infusion was used only after improvement had been achieved by intravenous infusion. Several times we had to replace the method by the intravenous one; either it was not suitable at all or the composition of fluids was wrong.
Intragastric infusion has proved a valuable therapeutic vomiting of any origin very seldom resists this treatment. I should be glad to hear from any of your readers who have had experience of enteral infusions. State Hospital, Children’s Department, S. J. HAVELKA. D&ebreve;&c aron;ín, Czechoslovakia. measure, and
CARDIAC OUTPUT AND RENAL BLOOD-FLOW IN SEVERE DEHYDRATION
SIR,-It is generally supposed that
an
inadequate
general circulation is associated with a reduction in renal blood-flow which is disproportionate to the reduction in cardiac output. Renal blood-flow has been determined in most cases by the clearance technique, though this seems an unreliable method when the diuresis is as in dehydration. We compared, in serial simultaneous determinations, the cardiac output (by the dye-dilution technique) and the renal blood-flow (by measuring directly the renal venous outflow) in narcotised dogs dehydrated by ligating the pylorus 72 hours before the experiment. The reduction in cardiac output was greater than expected from the fall in arterial pressure, so that the total peripheral resistance had increased. As determined by the direct technique there was a small decrease in the absolute value of renal blood-flow and the calculated renal vascular resistance was somewhat increased. The decrease in renal blood-flow was nearly proportional to the diminished cardiac output. Thus the renal fraction of cardiac output did not decrease during dehydration, as compared to the renal fraction determined by the same technique in normal dogs. On the basis of the p-aminohippuric acid clearance and extraction ratio a substantially reduced renal fraction was found. The clearance results suggested a nearly total renal ischxniia and an enormous increase in renal vascular resistance.
low,
A detailed account of
our
data is
to
be
published in Acta /1Iid1CJ
hungarica. P. BÁLINT J. STURCZ.
Physiological Institute, Medical University, Budapest. 1.
Havelka, S. J. Lancet, 1956, ii,
1312.
far been possible to discover whether the due to the presence of an activator or the disappearance of a serum inhibitor: any such inhibitor, which disappears at a temperature of 56°C maintained for 30 min, may be represented by a heat-labile fraction of the complement (Cl or Cl) which is destroved at that temnerature. Institute of Medical Pathology, V. ROSSI. University of Genoa. It has not
INTRAGASTRIC INFUSION
SIR,-In 1956,
ROBERT MARSHALL. ATTEMPTED SUICIDE
SIR,-It is impossible for authors to defend themselves against an anonymous review, even if they feel that their work has not received a fair appraisal. They have, however, the right to protest against misquotations. I am referring to the review (Sept. 6) of the book Attempted Suicide. In this and other books the term " suicidal act’-’ has been used for both suicide and attempted suicide. According to your review it was used only for the latter, which is quoted as having been regarded by the authors as not self-destructive. No such nonsense was asserted in the book. On the contrary, it was made quite clear that every suicidal act aimed at self-destruction but that the suicidal attempt could not be fully understood if this motivation alone was taken into consideration. E. STENGEL
* * * We much regret that our brief summary of the views of Professor Stengel and Miss Cook should have misrepresented them. Most authors will sympathise with him about the difficulty of defence against criticism in review; but this is no greater when the review is editorial than when it is personal. Our reviews, like our annotations and leaders, can be challenged.-ED. L. EFFECT OF INACTIVATED SERUM ON COLD AGGLUTININS SIR,-From the studies of Boorman and Dodd1 we learn that human serum can enhance the activity of
immune isoantibodies when it is used as a diluent instead of saline. Also in other immune systems (immune serum anti-sheep-red-cells or in Rose’s test for rheumatoid arthritis) human serum reveals this property. I have investigated whether normal human serum retains this property also in the titration of autoantibodies, and I chose the cold agglutinins as more readily titrable. serum
is used instead of saline, the titre of the cold
agglutinins increases but little; while if a previously inactivated (at 56°C for 30 min.) serum is used, there is a huge increase in the titre (from 1 : 4000 to 1 : 16 million in one case, and from 1 : 1000 to 1 : 4000 in another). The use of albumin or human gamma-globulin instead of serum does not bring about the phenomenon. Serums devoid of properdin have given similar results, as have also normal serums that have not been inactivated but kept at -20°C for months. Not all human serums show this considerable activation of the autoantibody titre: some, in fact, are incapable of producing it, while others increase the titre only slightly. one to two
1. Boorman, K. E., Dodd, B. E. J. Path. Bact. 1947,
59, 95.
you
were
good enough
to
publish
a
short communication about intragastric infusion in infants with acute dyspepsia.
doctors.
If fresh
so
phenomenon is
We have now used this method 140 times in infants, mainly for acute gastroenteritis. We gave physiological saline, Ringer’s or Darrow’s solutions, and 5 % glucose solution, the amount and proportions being the same as for parenteral infusions. Sometimes we added plasma substitutes. Sometimes plasma was given intravenously. In milder cases gastric infusion was combined with feeding by mouth or through the tube. We used polyethylene and rubber tubes, as thin as possible, passed through the nose. We have not seen any serious complications, even after leaving the tube in for several days. The effect on vomiting was striking. In severe gastroenteritis the rehydratation was often slower than by the intravenous route, but sometimes the result was almost equally good. In toxic gastroenteritis gastric infusion was used only after improvement had been achieved by intravenous infusion. Several times we had to replace the method by the intravenous one; either it was not suitable at all or the composition of fluids was wrong.
Intragastric infusion has proved a valuable therapeutic vomiting of any origin very seldom resists this treatment. I should be glad to hear from any of your readers who have had experience of enteral infusions. State Hospital, Children’s Department, S. J. HAVELKA. D&ebreve;&c aron;ín, Czechoslovakia. measure, and
CARDIAC OUTPUT AND RENAL BLOOD-FLOW IN SEVERE DEHYDRATION
SIR,-It is generally supposed that
an
inadequate
general circulation is associated with a reduction in renal blood-flow which is disproportionate to the reduction in cardiac output. Renal blood-flow has been determined in most cases by the clearance technique, though this seems an unreliable method when the diuresis is as in dehydration. We compared, in serial simultaneous determinations, the cardiac output (by the dye-dilution technique) and the renal blood-flow (by measuring directly the renal venous outflow) in narcotised dogs dehydrated by ligating the pylorus 72 hours before the experiment. The reduction in cardiac output was greater than expected from the fall in arterial pressure, so that the total peripheral resistance had increased. As determined by the direct technique there was a small decrease in the absolute value of renal blood-flow and the calculated renal vascular resistance was somewhat increased. The decrease in renal blood-flow was nearly proportional to the diminished cardiac output. Thus the renal fraction of cardiac output did not decrease during dehydration, as compared to the renal fraction determined by the same technique in normal dogs. On the basis of the p-aminohippuric acid clearance and extraction ratio a substantially reduced renal fraction was found. The clearance results suggested a nearly total renal ischxniia and an enormous increase in renal vascular resistance.
low,
A detailed account of
our
data is
to
be
published in Acta /1Iid1CJ
hungarica. P. BÁLINT J. STURCZ.
Physiological Institute, Medical University, Budapest. 1.
Havelka, S. J. Lancet, 1956, ii,
1312.