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NUTRITION AFTER MASSIVE INTESTINAL RESECTION
1062 size to the state of the placenta ; but cases of the type described by WRiGLEY are a distinct entity and may lead to great difficulty in delivery unless recognised in time. Unfortunately we still have no means of inducing labour immediately and without risk. Though the membranes be ruptured, labour may not begin in a day or even a week. What is then to bedone ? BRow--B-E 26 believes that, where the foetus is of thirtyfour or more weeks’ maturity and is normal, labour should never be induced surgically, unless the obstetrician is prepared to undertake caesarean section if delivery is not imminent after forty-eight hours. But some of those who would follow such a course for urgent induction because of maternal disorder, such as pre-eclamptic toxaemia, might nevertheless hesitate to adopt it for a normal person, anyhow in the fortnight after the expected date of confinement. The question here is not only when to induce labour, but also the lengths to which we should go when the simplest methods do not succeed. More precise methods of detecting ageing of the placenta would enable us to select more rationally cases for prompt. induction of labour.
Annotations NUTRITION AFTER MASSIVE INTESTINAL RESECTION THE time may come when the man with a middle-aged spread will present himself to the surgeon before seeking a life-assurance policy. Kremen et a1.27 have found that in dogs removal of the distal half of the small bowel is followed by lowered fat absorption and loss of weight, whereas removal of the proximal half has no such effect. In the clinical field, Henrikson excised part of the small bowel with the aim of correcting obesity, but the patient lost so much weight that it was difficult to strike a balance. Again in man, Kremen has added a touch of finesse by excluding, rather than excising, all but the terminal eighteen inches of the lower half of the small bowel; the excluded portion, opening distally into the transverse colon, is kept in abdominal store, as it were, so that if too much weight is being lost segments can be returned to activity by later operations. Accordingly the patient may eat to his stomach’s content and yet continue to lose weight. It seems that the absorption of fats may be affected selectively. Weckesser and Ankenny found that in dogs in which the distal two-thirds of the small intestine had been removed nitrogen was lost in the feces but to a lesser degree than fats, while carbohydrate excretion was unaffected 2B; but Kremen et al. found that the amount of nitrogen lost was to some extent linked to the fat excretion. Assessment of intestinal function is difficult since there is always a discrepancy between the results of absorption tests and the outcome of balance studies. Absorption tests are done individually for one of the three fundamental food elements, and a full load of the substance under investigation (methionine, for instance, if proteins are being considered) is given in a test dose. The gut may not be able to assimilate large quantities of such a substance, which it would receive in more dilute form in balance studies. Weckesser and Ankenny 211 tried the effect of vagal section on dogs after removal 26. Browne, J. C. McC. Proc. R. Soc. Med. 1952, 45, 532. 27. Kremen, A. J., Linner, J. H., Nelson, C. H. Ann. Surg. 1954, 140, 439. 28. Weckesser, E. C., Ankenny, J. L., Portman, A. F., Price, J. W., Cebul, F. A. Surgery, 1951, 30, 465
of two-thirds of the small intestine. Fat absorption was increased only if vagotomy was done soon after resection ; this effect seemed to be unrelated to the transit time -which is hardly surprising since in idiopathic steator. rhoea every opportunity for absorption is given to the gut by a natural delay in transit. It is unlikely that many surgeons will seriously consider resecting the small intestine for obesity ; but from time to time the problems of this operation come their war because, for example, of extensive mesenteric throm. bosis requiring wide resection, or Crohn’s disease requiring repeated resections. Haymond 29 surveyed 257 patients who for one reason or another had undergone massive Diarrhoea was the resection of the small intestine. commonest sequela ; this was often severe and even led to death. It was best controlled by reducing the fat intake, maintaining the protein balance, and giving plenty of carbohydrate. His finding that 50% is the upper limit for the amount of small bowel that may be safely removed accords with the experimental findings of Kremen and his colleagues, and with those of Trzebicky 30 and Monari 31 many years earlier. THE YOUNG DISABLED
WHAT with reablernent centres, disablement resettleofficers, the quota, Remploy, disability pensions,
ment
and the rest, we are apt to think we are doing reasonably well by the disabled. But Mrs. Sharp,32 surveying the social problems of the young disabled in Kent, found the needs of many of them so pressing that she could not merely record them and pass them by : in three out of every four homes which she visited she either gave much-needed advice herself or referred the haiidicapped person to appropriate agencies. She confined her survey to people aged between 15 and 45, and deliberately excluded all those disabled by blindness, deafness, epilepsy, mental defect, or pulmonary tuberculosis, and all who were in full-time employment. She found a gap in our service for the disabled at the outset : she had great difficulty in discovering them. None of the bodies who had to do with them maintained a complete list of disabled people. Thanks, however, to the help of 17 voluntary societies, 2 disabled people’s clubs, the Kent County Council, the National Assistance Board, and the Ministries of Pensions and Labour, she was given introductions to 576 people with disabilities, and in addition 65 long-stay patients Of this total of 641. were referred to her by hospitals. 419 were suitable for inclusion in the survey-212 men and 207 women.
psychosis,
Of the 65 hospital patients, 25 were in four small units reserved mainly for younger patients by the regional hospital board. Of the remaining 40, dotted about the county, only 14 wished to be moved so that they could enjoy younger company. The rest wanted either to stay near their relatives, or to go on getting some special treatment for their disabilities, in the hospitals where they were already patient. Places were found in the special units for 4 of those who wished for transfer ; but since there were no more places available, plans are being considered for collecting the rest in some other centre.
Mrs.
believes that most young patients, if they the choice on admission, would prefer to bee sent among their contemporaries, where they could hope for more liveliness and companionship than is possible in a chronic ward. And such companionship might well save some from the frustration which turns them into difficult characters as the years go by.
were
Sharp given
29. Haymond, H. E. Surg. Gynec. Obstet. 1935, 61, 693. 30. Trzebicky, R. Arch. kiln. Chir. 1894, 48, 54. 31. Monari, U. Beitr. klin. Chir. 1896, 16, 479. 32. Sharp, M. U. The Social Problems of Young Disabled Persons and Long-Stay Hospital Patients in Kent. Report submitted to the Leverhulme Research Awards and the South East Metropolitan Regional Hospital Board. 1954. Pp. 14.
Annotations NUTRITION AFTER MASSIVE INTESTINAL RESECTION THE time may come when the man with a middle-aged spread will present himself to the surgeon before seeking a life-assurance policy. Kremen et a1.27 have found that in dogs removal of the distal half of the small bowel is followed by lowered fat absorption and loss of weight, whereas removal of the proximal half has no such effect. In the clinical field, Henrikson excised part of the small bowel with the aim of correcting obesity, but the patient lost so much weight that it was difficult to strike a balance. Again in man, Kremen has added a touch of finesse by excluding, rather than excising, all but the terminal eighteen inches of the lower half of the small bowel; the excluded portion, opening distally into the transverse colon, is kept in abdominal store, as it were, so that if too much weight is being lost segments can be returned to activity by later operations. Accordingly the patient may eat to his stomach’s content and yet continue to lose weight. It seems that the absorption of fats may be affected selectively. Weckesser and Ankenny found that in dogs in which the distal two-thirds of the small intestine had been removed nitrogen was lost in the feces but to a lesser degree than fats, while carbohydrate excretion was unaffected 2B; but Kremen et al. found that the amount of nitrogen lost was to some extent linked to the fat excretion. Assessment of intestinal function is difficult since there is always a discrepancy between the results of absorption tests and the outcome of balance studies. Absorption tests are done individually for one of the three fundamental food elements, and a full load of the substance under investigation (methionine, for instance, if proteins are being considered) is given in a test dose. The gut may not be able to assimilate large quantities of such a substance, which it would receive in more dilute form in balance studies. Weckesser and Ankenny 211 tried the effect of vagal section on dogs after removal 26. Browne, J. C. McC. Proc. R. Soc. Med. 1952, 45, 532. 27. Kremen, A. J., Linner, J. H., Nelson, C. H. Ann. Surg. 1954, 140, 439. 28. Weckesser, E. C., Ankenny, J. L., Portman, A. F., Price, J. W., Cebul, F. A. Surgery, 1951, 30, 465
of two-thirds of the small intestine. Fat absorption was increased only if vagotomy was done soon after resection ; this effect seemed to be unrelated to the transit time -which is hardly surprising since in idiopathic steator. rhoea every opportunity for absorption is given to the gut by a natural delay in transit. It is unlikely that many surgeons will seriously consider resecting the small intestine for obesity ; but from time to time the problems of this operation come their war because, for example, of extensive mesenteric throm. bosis requiring wide resection, or Crohn’s disease requiring repeated resections. Haymond 29 surveyed 257 patients who for one reason or another had undergone massive Diarrhoea was the resection of the small intestine. commonest sequela ; this was often severe and even led to death. It was best controlled by reducing the fat intake, maintaining the protein balance, and giving plenty of carbohydrate. His finding that 50% is the upper limit for the amount of small bowel that may be safely removed accords with the experimental findings of Kremen and his colleagues, and with those of Trzebicky 30 and Monari 31 many years earlier. THE YOUNG DISABLED
WHAT with reablernent centres, disablement resettleofficers, the quota, Remploy, disability pensions,
ment
and the rest, we are apt to think we are doing reasonably well by the disabled. But Mrs. Sharp,32 surveying the social problems of the young disabled in Kent, found the needs of many of them so pressing that she could not merely record them and pass them by : in three out of every four homes which she visited she either gave much-needed advice herself or referred the haiidicapped person to appropriate agencies. She confined her survey to people aged between 15 and 45, and deliberately excluded all those disabled by blindness, deafness, epilepsy, mental defect, or pulmonary tuberculosis, and all who were in full-time employment. She found a gap in our service for the disabled at the outset : she had great difficulty in discovering them. None of the bodies who had to do with them maintained a complete list of disabled people. Thanks, however, to the help of 17 voluntary societies, 2 disabled people’s clubs, the Kent County Council, the National Assistance Board, and the Ministries of Pensions and Labour, she was given introductions to 576 people with disabilities, and in addition 65 long-stay patients Of this total of 641. were referred to her by hospitals. 419 were suitable for inclusion in the survey-212 men and 207 women.
psychosis,
Of the 65 hospital patients, 25 were in four small units reserved mainly for younger patients by the regional hospital board. Of the remaining 40, dotted about the county, only 14 wished to be moved so that they could enjoy younger company. The rest wanted either to stay near their relatives, or to go on getting some special treatment for their disabilities, in the hospitals where they were already patient. Places were found in the special units for 4 of those who wished for transfer ; but since there were no more places available, plans are being considered for collecting the rest in some other centre.
Mrs.
believes that most young patients, if they the choice on admission, would prefer to bee sent among their contemporaries, where they could hope for more liveliness and companionship than is possible in a chronic ward. And such companionship might well save some from the frustration which turns them into difficult characters as the years go by.
were
Sharp given
29. Haymond, H. E. Surg. Gynec. Obstet. 1935, 61, 693. 30. Trzebicky, R. Arch. kiln. Chir. 1894, 48, 54. 31. Monari, U. Beitr. klin. Chir. 1896, 16, 479. 32. Sharp, M. U. The Social Problems of Young Disabled Persons and Long-Stay Hospital Patients in Kent. Report submitted to the Leverhulme Research Awards and the South East Metropolitan Regional Hospital Board. 1954. Pp. 14.