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GASTROINTESTINAL PACING
1211 of vitamin A is apparently required to maintain epithelia in their normal state. Leereported a seasonal variation in the clinical onset of leukaemia in young people, but the observation seems to have little relevance to the seasonal birth date of persons with carcinoma of the bronchus. Clearly Dijkstra’s finding must be studied further. a
critical
amount
PERIPHERAL VASOMOTOR DISORDERS IN MIGRAINE
MIGRAINE is an episodic vasomotor disorder. If patients with migraine were found to have a generalised abnormality of vasomotor response, this might account for some of the extracranial symptoms. Several workers have claimed to demonstrate a generalised change. Appenzeller et al .6have examined the reflex response of blood-flow in the hands of migraineurs. They found that in such subjects warmth applied to the chest led to no vasodilatation in the hand. A vasodilator response is normal,’ and was in fact obtained by Appenzeller and his colleagues in a small control group of subjects without migraine. Reflex vasoconstriction, in so far as it was tested, seemed to be the same in both groups. These findings could support the view that some general abnormality of vasomotor response does exist in migraine. It will be of considerable interest to see whether the observations are confirmed. ALCOHOL AND ASTHMA
IN a previous issue Salter8 noted that alcohol might relieve an asthmatic attack, but after a century information Now Herxheimer and on this point is still scanty. Stresemann 9 report the effects of alcohol on the vital capacities of 6 healthy people and 23 chronic asthmatics (19 males and 4 females). The subjects were given 40-80 ml. (usually 40 ml.) of brandy or vodka containing 38-40% ethanol. The vital capacity was recorded at five-minute intervals. In the normal subjects the vital capacity remained unchanged, but in 20 of the 23 asthmatics it increased by 6-38% (mean 13%), and the increase was usually accompanied by subjective improvement. The increase began about ten minutes after ingestion of the alcohol, reached its peak after twenty-five to thirty minutes, and began to decline after about an hour. Owing to the difficulty of disguising the flavour and effects of alcoholic drinks, placebos were not used for control experiments; but the authors point out that psychological factors are unlikely to have caused the increase since it did not reach its peak until about half an hour after ingestion of the dose. Moreover, administration of pure ethanol to 2 patients in a dose equivalent to that given in vodka or
brandy produced comparable improvement. Herxheimer and Stresemann 10 draw attention to another effect of alcohol in asthmatics. In experimental work the administration of bradykinin by aerosol had been found to produce a slight increase in bronchospasm, but in 1 patient it caused an explosive asthmatic attack. Subsequent inquiry revealed that the patient before presenting himself had taken 8 or 9 glasses of schnaps (though not apparently with any thought of improving his vital capacity). The 5. Lee, J. A. H. Brit. med. J. 1962, 6. Appenzeller, O., Davidson, K.,
i, 1737. Marshall, J. J. Neurol. Neurosurg. Psychiat. 1963, 26, 447. 7. Kirslche, D. Mk., Cooper, K. E. Clin. Sci. 1950, 9, 31. 8. Salter, H. H. Lancet, 1863, ii, 558. 9. Herxheimer, H., Stresemann, E. Arch. int. Pharmacodyn. 1963, 144, 310. 10. Herxheimer, H., Stresemann, E. ibid. p. 315.
possibility that alcohol might intensify the bradykinin effect was therefore investigated. 6 healthy persons and 15 asthmatics were first given 0’5% bradykinin aerosol to ascertain the extent of their reactions; and after the effect, if any, had passed off, they were each given 10-140 ml. (mostly 40 ml.) of brandy or vodka containing 38-40% ethanol. Twenty-five to thirty minutes later, at the peak of the alcohol effect, they were given the same amount of bradykinin as before. Bradykinin alone reduced the vital capacity of only 1 of the 6 healthy subjects: after alcohol had been given, bradykinin produced a greater reduction in this subject, and also a reduction in 2 of the others. Bradykinin alone reduced the vital capacity in all 15 asthmatics: after alcohol it reduced the vital capacity by a still greater margin in 9 instances; and in 5 of these 9 patients bronchospasm was severe. So far Herxheimer and Stresemann cannot explain why alcohol usually tends to relieve bronchospasm in asthma but often intensifies the bronchospastic effect of bradykinin. GASTROINTESTINAL PACING
AFTER most abdominal operations, intestinal motility is abolished for some hours or even for a day or two,1but the condition may become self-perpetuating as increasing distension from accumulation of intestinal secretions and swallowed and bacterial gas aggravates the paresis and establishes a vicious circle. The management of postoperative ileus has generally been accepted as calling for suction drainage and intravenous fluid therapy (since suction removes large quantities of salt and water from the body) until the bowel resumes tone and activity. Though regarded as essential by many surgeons and therefore tolerated by most patients, an indwelling gastric tube undoubtedly contributes to postoperative discomfort, increases the risk of pulmonary complications, and, if used for a long time, may damage the lower oesophagus either directly or from reflux of acid-pepsin, because of impaired efficiency of the oesophago-gastric junction. Reassessment of the need for these measures is certainly overdue; for much has recently been added to knowledge of the extent and severity of small-bowel paralysis after abdominal surgery. Wangensteen2 has emphasised that the term paralytic ileus is ill-fitted to describe the meteorism and motor inactivity, and other observers 34 have provided evidence that the bowel is inhibited rather than paralysed and can still respond to stimulation. A recent paper by Lillehei et al. adds further support to this view, and describes a method of treatment by direct electrical stimulation of the gastrointestinal tract by means of a specially designed electronic pacemaker. Impressed with the success of the cardiac pacemaker in complete heart-block and arguing from the observation that a stimulus applied to the small bowel, besides causing local contraction, can also induce a peristaltic rush, the American workers designed experiments in dogs to determine the best types of current and sites for stimulation. The results, tested and modified in man, showed that a current of 7-10 mA with an impulse frequency of 50 cycles per second given for 5 seconds was sufficient to induce peristalsis judged by barium examination of healthy subjects, and later by direct observation of the bowel at laparotomy. A pacemaker area has been des1. 2. 3. 4. 5.
Wakim, K. G., Mann, F. C. Gastroenterology, 1943, 1, 513. Wangensteen, O. H. Intestinal Obstruction. Springfield, Ill., 1955. Frey, S. Arch. klin. Chir. 1926, 142, 445. Hotz, G. Cited by Bilgutay et al. (ref. 5) Bilgutay, A. M., Winrove, R., Griffen, W. O., Bonnabeau, R. C., Lillehei, C. W. Ann. Sure. 1963, 158, 338.
1212 PORTRAITS OF PHYSICIANS cribed in the second part of the duodenum,67, and, though of the studies various areas were FEw books (it has been said) provide more material for fully comparable not made, Lillehei et al. found that the most effective afterdinner speeches than Munk’s Roll of the Royal College peristaltic activity generally followed stimulation of the of Physicians, and certainly it is enjoyable bedside reading. gastric antrum and the first and second parts of the For its lack of illustrations, the Ciba Foundation has now duodenal loop. A plastic tube carrying a brass-tipped provided a book of portraits of the fellows throughout the electrode was passed through the nose and served the centuries. It may not be a representative cross-section, dual purpose of suction and electrical activation. The since the unsuccessful, the insignificant, and the imindifferent electrode, a 5 x 5 in. plate, was strapped to pecunious are unlikely to be represented In the college’s either the anterior or posterior abdominal wall, and both collection; but it is none the less fascinating. electrodes were connected to a pacemaker delivering The content of the volume is, quite simply, all (or impulses at intervals of one minute. The device is almost all) the portraits in paint, pencil, marble, or bronze described by Dr. Sanchez in a letter in this issue. The the college. It has not, unfortunately, been a by possessed rectal route also was found to be effective in restoring habit to have the portrait of every president or famous peristaltic activity to the upper gastrointestinal tract, but fellow painted: and, since the collection is made up of stimulation of the antrum (where gastric activity is and legacies, it is a mixed lot. The fellows portrayed gifts greatest) is generally preferred to other areas of the range from the notable to the notorious, and the less bowel; in patients with ileus, pacing is continued until distinguished have sometimes been the more entertaining. the passage of flatus and the first stool. none of these portraits are of men who were hanged Lillehei et al. report the use of the method in 45 patients True, or expelled from the fellowship, but the list does include after various operations, including gastrectomy, vagotomy, like Messenger Monsey, that extraordinary cholecystectomy, and colectomy, and in reflex ileus figures eccentric (if no worse: the accompanying secondary to renal colic. Pacing was generally begun 18th-century is a kind one) who has the advantage of having biography within a few hours of operation, and peristaltic activity, one of the most remarkable of all the college’s portraits. judged by the passage of flatus, returned in an average Many of the most distinguished and interesting of the of twenty hours instead of fifty-five hours in a nonfellows have no picture in the college: Sir William Gull, stimulated group. Though it has not become their policy for instance. But some of these may come, especially now to dispense with gastric suction and intravenous fluids, has been drawn to the collection. Lillehei et al. believe that the earlier return of bowel that attention The Ciba Foundation is to be warmly congratulated on activity achieved by gastrointestinal pacing has materially reduced the time during which these measures are needed the book. The pencil drawings, which include many by and has permitted the earlier institution of oral feeding, George Dance, come out well, but so do the paintings, itself a further stimulus to peristalsis. including the pastel on cloth on p. 61-an impression of Despite the relatively crude clinical measurements and rare quality. Some of the oil paintings look much better the lack of any controlled observations, the method in reproduction than the originals, notably the one of Sir William Osler. The portrait of Linacre, too, hardly loses warrants further assessment. Its introduction comes at a time when postoperative suction and intravenous fluid by not being in colour; and it is a remarkable picture in its are to be own right, having been copied from the portrait at Windsor after therapy tending replaced by early feeding 9 most gastric operations. Kay’s group at Sheffield used by the college beadle in 1810-so well that it shows no the radio-telemetering capsule to study intestinal motility trace of that almost universal fault of copies, a greater after various operations. Small ]rowel movements returned resemblance to contemporary portraits than to its original. within an hour of operations that did not entail the (Vide, for instance, the copy of the portrait of Sir William handling of viscera and in a mean of four hours after Butts on p. 103, which converts a Tudor worthy into a gastric operations without vagotomy. These periods are Victorian, and a sentimental one at that.) The portraits surprisingly brief, and the lack of ileus in this group have been annotated by Mr. David Piper, who (we trust as scarcely suggests a need for further help. Vagotomy a result of this remarkable piece of work) is to be director inhibited small-bowel motility for a mean of ten hours- of the National Portrait Gallery. It consists of a scholarly series of notes, the result of much research and expert more than double the period of stagnation after gastric the time for capsule knowledge. With their aid, the book is virtually a history surgery without vagus section-but of English portraiture, for nearly all the great portraitexcretion was the same in both groups. This work painters and sculptors are represented, and a good many suggests that vagotomy only slightly affects small-bowel motility, and in practice the small intestine seems capable amateurs and oddities, such as the Chinese modeller of transporting its contents within twenty-four hours of Chitqua, who was marooned by sailors in England.
operation. Gastrointestinal pacing seems unlikely ever to gain a comfortable place in routine postoperative care. But perhaps in the patient with prolonged motor inhibition after vagotomy and possibly as an aid in the differential diagnosis between mechanical obstruction and paralytic ileus, gastrointestinal pacing may rescue the surgeon from the anxiety of stalemate and the patient from the burden of prolonged suction drainage and intravenous alimentation. 8.
Hasselbrack, R., Thomas, J. E. Amer. J. Physiol. 1961, 201, 955. Milton, G. W., Smith, A. W. M. J. Physiol. 1956, 132, 100. Welbourn, R. B., Johnston, I. D. A. in British Surgical Practice: Surgical Progress (edited by E. R. Carling and J. Patterson Ross).
9.
London, 1961. Ross, B., Watson, B. W., Kay, A. W. Gut, 1963, 4, 77.
6. 7.
The pictures are accompanied by excellent brief biographies, largely by Dr. J. B. Harman and Mr. L. M. Payne. The whole has been edited and put together with care and skill by Dr. Gordon Wolstenholme, who also had the quickness to seize at once the original idea, put to him by Dr. Chauncey D. Leake, the medical historian from
Ohio, who well deserves the mention he gets in the preface. Altogether, this book is a credit to all concerned, and its issue is a happy way of commemorating the college’s
impending move Regent’s Park.
to
the
new
home
being built
for it in
1. Portraits of the Royal College of Physicians of London. Edited by GORDON WOLSTENHOLME, M.R.C.P.; the portraits described by DAVID PIPER. London: J. & A. Churchill. 1964. Pp. 468. 75s.
critical
amount
PERIPHERAL VASOMOTOR DISORDERS IN MIGRAINE
MIGRAINE is an episodic vasomotor disorder. If patients with migraine were found to have a generalised abnormality of vasomotor response, this might account for some of the extracranial symptoms. Several workers have claimed to demonstrate a generalised change. Appenzeller et al .6have examined the reflex response of blood-flow in the hands of migraineurs. They found that in such subjects warmth applied to the chest led to no vasodilatation in the hand. A vasodilator response is normal,’ and was in fact obtained by Appenzeller and his colleagues in a small control group of subjects without migraine. Reflex vasoconstriction, in so far as it was tested, seemed to be the same in both groups. These findings could support the view that some general abnormality of vasomotor response does exist in migraine. It will be of considerable interest to see whether the observations are confirmed. ALCOHOL AND ASTHMA
IN a previous issue Salter8 noted that alcohol might relieve an asthmatic attack, but after a century information Now Herxheimer and on this point is still scanty. Stresemann 9 report the effects of alcohol on the vital capacities of 6 healthy people and 23 chronic asthmatics (19 males and 4 females). The subjects were given 40-80 ml. (usually 40 ml.) of brandy or vodka containing 38-40% ethanol. The vital capacity was recorded at five-minute intervals. In the normal subjects the vital capacity remained unchanged, but in 20 of the 23 asthmatics it increased by 6-38% (mean 13%), and the increase was usually accompanied by subjective improvement. The increase began about ten minutes after ingestion of the alcohol, reached its peak after twenty-five to thirty minutes, and began to decline after about an hour. Owing to the difficulty of disguising the flavour and effects of alcoholic drinks, placebos were not used for control experiments; but the authors point out that psychological factors are unlikely to have caused the increase since it did not reach its peak until about half an hour after ingestion of the dose. Moreover, administration of pure ethanol to 2 patients in a dose equivalent to that given in vodka or
brandy produced comparable improvement. Herxheimer and Stresemann 10 draw attention to another effect of alcohol in asthmatics. In experimental work the administration of bradykinin by aerosol had been found to produce a slight increase in bronchospasm, but in 1 patient it caused an explosive asthmatic attack. Subsequent inquiry revealed that the patient before presenting himself had taken 8 or 9 glasses of schnaps (though not apparently with any thought of improving his vital capacity). The 5. Lee, J. A. H. Brit. med. J. 1962, 6. Appenzeller, O., Davidson, K.,
i, 1737. Marshall, J. J. Neurol. Neurosurg. Psychiat. 1963, 26, 447. 7. Kirslche, D. Mk., Cooper, K. E. Clin. Sci. 1950, 9, 31. 8. Salter, H. H. Lancet, 1863, ii, 558. 9. Herxheimer, H., Stresemann, E. Arch. int. Pharmacodyn. 1963, 144, 310. 10. Herxheimer, H., Stresemann, E. ibid. p. 315.
possibility that alcohol might intensify the bradykinin effect was therefore investigated. 6 healthy persons and 15 asthmatics were first given 0’5% bradykinin aerosol to ascertain the extent of their reactions; and after the effect, if any, had passed off, they were each given 10-140 ml. (mostly 40 ml.) of brandy or vodka containing 38-40% ethanol. Twenty-five to thirty minutes later, at the peak of the alcohol effect, they were given the same amount of bradykinin as before. Bradykinin alone reduced the vital capacity of only 1 of the 6 healthy subjects: after alcohol had been given, bradykinin produced a greater reduction in this subject, and also a reduction in 2 of the others. Bradykinin alone reduced the vital capacity in all 15 asthmatics: after alcohol it reduced the vital capacity by a still greater margin in 9 instances; and in 5 of these 9 patients bronchospasm was severe. So far Herxheimer and Stresemann cannot explain why alcohol usually tends to relieve bronchospasm in asthma but often intensifies the bronchospastic effect of bradykinin. GASTROINTESTINAL PACING
AFTER most abdominal operations, intestinal motility is abolished for some hours or even for a day or two,1but the condition may become self-perpetuating as increasing distension from accumulation of intestinal secretions and swallowed and bacterial gas aggravates the paresis and establishes a vicious circle. The management of postoperative ileus has generally been accepted as calling for suction drainage and intravenous fluid therapy (since suction removes large quantities of salt and water from the body) until the bowel resumes tone and activity. Though regarded as essential by many surgeons and therefore tolerated by most patients, an indwelling gastric tube undoubtedly contributes to postoperative discomfort, increases the risk of pulmonary complications, and, if used for a long time, may damage the lower oesophagus either directly or from reflux of acid-pepsin, because of impaired efficiency of the oesophago-gastric junction. Reassessment of the need for these measures is certainly overdue; for much has recently been added to knowledge of the extent and severity of small-bowel paralysis after abdominal surgery. Wangensteen2 has emphasised that the term paralytic ileus is ill-fitted to describe the meteorism and motor inactivity, and other observers 34 have provided evidence that the bowel is inhibited rather than paralysed and can still respond to stimulation. A recent paper by Lillehei et al. adds further support to this view, and describes a method of treatment by direct electrical stimulation of the gastrointestinal tract by means of a specially designed electronic pacemaker. Impressed with the success of the cardiac pacemaker in complete heart-block and arguing from the observation that a stimulus applied to the small bowel, besides causing local contraction, can also induce a peristaltic rush, the American workers designed experiments in dogs to determine the best types of current and sites for stimulation. The results, tested and modified in man, showed that a current of 7-10 mA with an impulse frequency of 50 cycles per second given for 5 seconds was sufficient to induce peristalsis judged by barium examination of healthy subjects, and later by direct observation of the bowel at laparotomy. A pacemaker area has been des1. 2. 3. 4. 5.
Wakim, K. G., Mann, F. C. Gastroenterology, 1943, 1, 513. Wangensteen, O. H. Intestinal Obstruction. Springfield, Ill., 1955. Frey, S. Arch. klin. Chir. 1926, 142, 445. Hotz, G. Cited by Bilgutay et al. (ref. 5) Bilgutay, A. M., Winrove, R., Griffen, W. O., Bonnabeau, R. C., Lillehei, C. W. Ann. Sure. 1963, 158, 338.
1212 PORTRAITS OF PHYSICIANS cribed in the second part of the duodenum,67, and, though of the studies various areas were FEw books (it has been said) provide more material for fully comparable not made, Lillehei et al. found that the most effective afterdinner speeches than Munk’s Roll of the Royal College peristaltic activity generally followed stimulation of the of Physicians, and certainly it is enjoyable bedside reading. gastric antrum and the first and second parts of the For its lack of illustrations, the Ciba Foundation has now duodenal loop. A plastic tube carrying a brass-tipped provided a book of portraits of the fellows throughout the electrode was passed through the nose and served the centuries. It may not be a representative cross-section, dual purpose of suction and electrical activation. The since the unsuccessful, the insignificant, and the imindifferent electrode, a 5 x 5 in. plate, was strapped to pecunious are unlikely to be represented In the college’s either the anterior or posterior abdominal wall, and both collection; but it is none the less fascinating. electrodes were connected to a pacemaker delivering The content of the volume is, quite simply, all (or impulses at intervals of one minute. The device is almost all) the portraits in paint, pencil, marble, or bronze described by Dr. Sanchez in a letter in this issue. The the college. It has not, unfortunately, been a by possessed rectal route also was found to be effective in restoring habit to have the portrait of every president or famous peristaltic activity to the upper gastrointestinal tract, but fellow painted: and, since the collection is made up of stimulation of the antrum (where gastric activity is and legacies, it is a mixed lot. The fellows portrayed gifts greatest) is generally preferred to other areas of the range from the notable to the notorious, and the less bowel; in patients with ileus, pacing is continued until distinguished have sometimes been the more entertaining. the passage of flatus and the first stool. none of these portraits are of men who were hanged Lillehei et al. report the use of the method in 45 patients True, or expelled from the fellowship, but the list does include after various operations, including gastrectomy, vagotomy, like Messenger Monsey, that extraordinary cholecystectomy, and colectomy, and in reflex ileus figures eccentric (if no worse: the accompanying secondary to renal colic. Pacing was generally begun 18th-century is a kind one) who has the advantage of having biography within a few hours of operation, and peristaltic activity, one of the most remarkable of all the college’s portraits. judged by the passage of flatus, returned in an average Many of the most distinguished and interesting of the of twenty hours instead of fifty-five hours in a nonfellows have no picture in the college: Sir William Gull, stimulated group. Though it has not become their policy for instance. But some of these may come, especially now to dispense with gastric suction and intravenous fluids, has been drawn to the collection. Lillehei et al. believe that the earlier return of bowel that attention The Ciba Foundation is to be warmly congratulated on activity achieved by gastrointestinal pacing has materially reduced the time during which these measures are needed the book. The pencil drawings, which include many by and has permitted the earlier institution of oral feeding, George Dance, come out well, but so do the paintings, itself a further stimulus to peristalsis. including the pastel on cloth on p. 61-an impression of Despite the relatively crude clinical measurements and rare quality. Some of the oil paintings look much better the lack of any controlled observations, the method in reproduction than the originals, notably the one of Sir William Osler. The portrait of Linacre, too, hardly loses warrants further assessment. Its introduction comes at a time when postoperative suction and intravenous fluid by not being in colour; and it is a remarkable picture in its are to be own right, having been copied from the portrait at Windsor after therapy tending replaced by early feeding 9 most gastric operations. Kay’s group at Sheffield used by the college beadle in 1810-so well that it shows no the radio-telemetering capsule to study intestinal motility trace of that almost universal fault of copies, a greater after various operations. Small ]rowel movements returned resemblance to contemporary portraits than to its original. within an hour of operations that did not entail the (Vide, for instance, the copy of the portrait of Sir William handling of viscera and in a mean of four hours after Butts on p. 103, which converts a Tudor worthy into a gastric operations without vagotomy. These periods are Victorian, and a sentimental one at that.) The portraits surprisingly brief, and the lack of ileus in this group have been annotated by Mr. David Piper, who (we trust as scarcely suggests a need for further help. Vagotomy a result of this remarkable piece of work) is to be director inhibited small-bowel motility for a mean of ten hours- of the National Portrait Gallery. It consists of a scholarly series of notes, the result of much research and expert more than double the period of stagnation after gastric the time for capsule knowledge. With their aid, the book is virtually a history surgery without vagus section-but of English portraiture, for nearly all the great portraitexcretion was the same in both groups. This work painters and sculptors are represented, and a good many suggests that vagotomy only slightly affects small-bowel motility, and in practice the small intestine seems capable amateurs and oddities, such as the Chinese modeller of transporting its contents within twenty-four hours of Chitqua, who was marooned by sailors in England.
operation. Gastrointestinal pacing seems unlikely ever to gain a comfortable place in routine postoperative care. But perhaps in the patient with prolonged motor inhibition after vagotomy and possibly as an aid in the differential diagnosis between mechanical obstruction and paralytic ileus, gastrointestinal pacing may rescue the surgeon from the anxiety of stalemate and the patient from the burden of prolonged suction drainage and intravenous alimentation. 8.
Hasselbrack, R., Thomas, J. E. Amer. J. Physiol. 1961, 201, 955. Milton, G. W., Smith, A. W. M. J. Physiol. 1956, 132, 100. Welbourn, R. B., Johnston, I. D. A. in British Surgical Practice: Surgical Progress (edited by E. R. Carling and J. Patterson Ross).
9.
London, 1961. Ross, B., Watson, B. W., Kay, A. W. Gut, 1963, 4, 77.
6. 7.
The pictures are accompanied by excellent brief biographies, largely by Dr. J. B. Harman and Mr. L. M. Payne. The whole has been edited and put together with care and skill by Dr. Gordon Wolstenholme, who also had the quickness to seize at once the original idea, put to him by Dr. Chauncey D. Leake, the medical historian from
Ohio, who well deserves the mention he gets in the preface. Altogether, this book is a credit to all concerned, and its issue is a happy way of commemorating the college’s
impending move Regent’s Park.
to
the
new
home
being built
for it in
1. Portraits of the Royal College of Physicians of London. Edited by GORDON WOLSTENHOLME, M.R.C.P.; the portraits described by DAVID PIPER. London: J. & A. Churchill. 1964. Pp. 468. 75s.