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ROLE OF CHLORIDE IN THE CORRECTION OF ALKALOSIS ASSOCIATED WITH POTASSIUM DEPLETION
447 Lactose intolerance was confirmed and the investigation for possible mucosal disaccharidase deficiency was begun. A small-bowel suction biopsy was obtained with the Crosby capsule. The patient had fasted for six hours. No sedation was used. The capsule was 90 cm. from the teeth and was fluoroscopically located in the proximal jejunum. A 20 ml.syringe was used first to clear the -tube and capsule, then to Approximately 1000 infants and children suffering from apply suction for triggering the knife within the capsule. No severe malnutrition (kwashiorkor) are admitted to this, departresistance was noted during the introduction of air. Suction ment each year. The mortality-rate over the past year was 24%. was applied by a smooth, moderately rapid withdrawal of the During this period 37 cases were found to be suffering from plunger. Neither the patient nor the operator of the syringe hypoglycsemia (blood-sugar levels below 30 mg. per 100 ml.), was aware of closure of the knife. Attempted reintroduction of whom 33 died. Blood-sugar levels below 10 mg. were of air was met with resistance indicating closure of the knife. recorded in 32 of the fatal cases. Thus 14% of the deaths in The capsule was slowly and easily withdrawn until it was were associated with our series kwashiorkor patients 60 cm. from the teeth-i.e., near the pylorus. Constant, gentle hypoglycaemia. traction did not deliver the capsule but after positioning the The features described by McLean in his fatal cases may patient on her hands and knees, a " gag " led to recovery of well have been due to hypoglycsemia which tends to occur in the capsule. It was assumed that the capsule had been temmalnourished infants with severe hepatomegaly. Malnourished porarily held up at the pylorus. This is not uncommon. A infants and children with low blood-sugar levels do not sweat2 good-sized specimen was obtained, which was immediately and rarely show any evidence of tremors or convulsions.3 If frozen in preparation for the future enzyme determinations. untreated, however, they lapse into coma and usually die. The patient felt quite well after this and was allowed a meal. Anorexia and refusal of feeds are frequent, and some This consisted of fried meat and bread, and tea. patients travel long distances without provision for feeds en Shortly after the meal, and about 45potatoes, minutes after the biopsy, route. After arrival at hospital there may be further delay she had sudden, severe, generalised abdominal pain. On before feeds are given, or the child refuses the feed offered, examination she showed typical signs of peritonitis. Rebound This inadvertent deprivation of carbohydrate intake may aggratenderness was present in the left upper abdominal quadrant. vate an underlying inability to maintain the blood-glucose The symptoms increased in severity and she vomited. Surgical level resulting from defective gluconeogenesis.4 exploration was undertaken about 4 hours after the onset of Dehydration, ansmia, and infection played little or no part the symptoms. The findings included small collections of in our group of fatal cases, and the major necropsy finding has cloudy peritoneal fluid near the ligament of Treitz and in the been restricted to a large fatty liver. In those subjects whose area between the spleen and stomach. This material was culjugular venous blood samples were found to have sugar levels tured. Fibrinous exudates were present at both sites. Extensive below 20 to 30 mg. per 100 ml. and who died in spite of revealed no perforation. Methylene-blue was immediate treatment, needle-biopsy specimens of the liver taken investigation into the stomach through a nasogastic tube and introduced immediately at death showed that the fat-laden cells were milked through the pylorus, duodenum, the entire length of devoid of glycogen. the small intestine, and into the colon. No perforation was In our department it has now become routine for a malfound. A full-thickness biopsy of the small intestine was made nourished child showing signs of apathy or anorexia to have about one ft. proximal to the jejunocolic anastomosis. an immediate blood sample taken for sugar estimation, and an The postoperative course was uneventful. The intestinal intravenous injection of 50% dextrose is given. This is obtained at surgery showed signs of recent biopsy-specimen a intravenous of followed infusion by continuous promptly and a normal mucosa. Escherichia coli was cultured peritonitis chloride solution to has dextrose in sodium which 0-2% 5% from the peritoneal fluid. Although no perforation was found, been added 26 mEq. of potassium acetate per litre. The intravenous electrolyte solutions are later adjusted according it was apparent that this patient had peritonitis. She had the classical symptoms and physical finding of peritonitis, cloudy to the biochemical and clinical findings. fluid that cultured Esch. coli and biopsy evidence of peritoneal In spite of our awareness of the problem and steps
HEPATIC FAILURE IN MALNUTRITION SiR.—Dr. McLeanstates that " the most important death in malnutrition are infection, treatable causes dehydration, potassium deficiency, and perhaps folic-acid deficiency ". He has, however, overlooked hypoglycxmia, which we believe is a relatively important cause of death.
a
of
combat low blood-sugars, most of our hypoglycsemic patients have died, possibly owing to irreversible cerebral damage. It has become evident that more active steps are necessary to prevent any long period of starvation in malnourished children, with consequent hope of reduction in the numbers dying from hypoglycaemia.
taken
to
Baragwanath Hospital, Johannesburg.
S. WAYBURNE.
PERITONITIS AFTER JEJUNAL BIOPSY WITH CROSBY CAPSULE
SIR,-In connection with the letter5 of Dr. Shackleton and Dr. Haas, we wish to report a case of peritonitis in an adult after the use of the Crosby capsule to obtain a jejunal mucosal biopsy specimen. Intestinal malabsorption was investigated in a 22-year-old who had
lifelong history of milk intolerance. A normal D-xylose absorption, and a normal jejunal mucosa on X-ray examination and by biopsy through a Rubin tube, were found at another hospital. Her ileum had been previously removed surgically because of an internal hernia.
woman
a
1. McLean, A. E. Lancet, 1962, ii, 1292. 2. Kahn, B. S. Afr. med. J. 1954, 28, 110. 3. Kahn, E., Wayburne, S. Proc. Nutr. Soc. S. Afr. 1960, 1, 21. 4. Slone, D., Taitz, L. S., Gilchrist, G. S. Brit. med. J. 1961, i, 32. 5. See Lancet, 1962, ii, 989.
a recent
peritonitis.
Peritonitis probably would not have arisen if this patient had not eaten. The supposition is that peristalsis and increased intraluminal pressure caused intestinal contents to escape through a minute perforation at the biopsy site. This hole was sealed by the time of operation. This perforation occurred in a young adult with a histologically normal small bowel. The reason for this perforation is not known, but the capsule has a large mucosal port (3-6 mm. diameter) and it is operated without manometric control. These factors might increase the
likelihood of
perforation.
Department of Medicine,
University of Colorado Medical Center, Denver 20, Colorado U.S.A.
JOHN E. STRUTHERS, Jr. WAYNE L. ATTWOOD FRED KERN, Jr.
ROLE OF CHLORIDE IN THE CORRECTION OF ALKALOSIS ASSOCIATED WITH POTASSIUM DEPLETION
SIR,-We have read with interest the communication of Dr. Aber and his colleagues. They found low or normal values of PC02 in cases of combined hypochlorxmic and hypokalaemic alkalosis. Commenting on their paper, Dr. 1.
Aber, G. M., Sampson, P. A., Whitehead, 1962, ii, 1028.
T.
P., Brooke, B. N. Lancet,
448
technique for measuring high PC02 values in combined hypochloraemic and hypokalaonic alkalosis. Fig. 2 shows cumulative electrolyte balances, electrolyte concentrations, and data about the acid-base equilibrium in a patient with obstruction of the pylorus by gastric carcinoma. On admission, the patient was hypokalxmic (plasma-potassium 2-5 mEq. per litre) and extremely hypochlorxmic (plasma-chloride 64 mEq. per litre). The blood pH and Pco2 values, measured with Astrup’s method, were 7-558 and 64 mm. Hg. In the course of correction of the hypochlorxmia with saline infusions the PC02 became normal (43 mm. Hg), but the potassium balance was only slightly positive. Mild hypokalaemia (plasma-potassium 3’2 mEq. per litre on the 8th day) as well as a pure metabolic alkalosis (blood pH 7-545) persisted. Gastrectomy was performed. Two weeks later, when the metabolic alkalosis had disappeared, the
plasma-potassium and chloride values were normal. These findings show that high Pcoz values can be measured in hypokalaemic alkalosis, using Astrup’s technique. Moreover, they show that by correcting the chloride depletion a high Pc02 in mixed hypochlorasmic and hypokalxmic alkalosis can disappear, in spite of persisting alkalosis and hypokalxmia. Fig. 1-Reconstructed pH-log Pcoa lines in Astrup’s using the data of Aber et al.
Department of Internal Medicine, Radboud Hospital, University of Nijmegen,
nomogram,
The Netherlands.
questions the validity of Astrup’s method3 of measuring Pco2 in the presence of potassium depletion.
P. W. C. KLOPPENBORG A. P. JANSEN.
Polak2
Using Aber’s data about blood pH, Pco2, and standard bicarbonate, we reconstructed pH-log Pco2 lines in Astrup’s nomogram. We were surprised at the slope of these lines in cases 1, 4, and 5 (fig. 1). With reference to Dr. Polak’s comment, we submit the following observation to show the suitability of Astrup’s 2. 3.
Polak, A. ibid. p. 1275. Astrup, P., Jørgensen, K., Andersen, O. S., Engel, K. ibid. 1960, i, 1035.
ATTEMPTED SUICIDE
SIR,-Dr. Asher (Feb. 16) questions whether everyone who attempts suicide must see a psychiatrist. Few would disagree that a general physician who has the experience gained from constant and prolonged acquaintance with these patients, and the necessary time to devote, may decide what to do. More important than the style of the doctor who sees the is that somebody should see an independent informant before the patient is interviewed. Here, a psychiatric social worker does this and it takes him half-an-hour or more. Time and again we found that we erred before we made this a rule. Patients keen to leave hospital often conceal crucial pieces of information relevant to their disposal. During the past few months we would otherwise have discharged, to care for their young families, two women, in ignorance that they had had to be restrained from infanticide on the day before admission. There are many other examples we could give. The immediate happenings of the overdose, elicited from a relative or sometimes only from a police or ambulance man, are As Professor Stengel points out (Feb. 2) we not sufficient. need to know all the patient’s circumstances relevant to the attempt. Armed with this knowledge the physician interviewing the patient knows what to look for and what to ask about. If he follows this course he is not likely to err, except on the side of caution; but if he does not he may never realise the mistakes he makes.
patient
Department of Psychological Medicine, Royal Infirmary, Edinburgh. "
SIR,-The " operative is surely, "Some of them
sentence
NEIL KESSEL. of Dr. Asher’s letter
justfed-up’ and seek a holiday from the tedium of existence by taking a big sleep, and not caring about the risk ". I have italicised the because this word just highlights the two possible of the either that to put your life sentence: implications into jeopardy simply because you are fed-up is trivial (if this is the meaning, I disagree on moral grounds); or that problems of this type do not need assiduous investigations and handling (if it means this, I disagree on medical grounds). Let, indeed, the general physician of Dr. Asher’s psychiatric inclinations himself handle the personality "
are
"
"
Fig. 2-A woman of 39 with pyloric obstruction. Cumulative electrolyte balances, plasma-electrolyte concentrations, values for blood pH, Pco., and standard bicarbonate during the correction of hypochloreemie hypokalactnic alkalosis.
"
"
HEPATIC FAILURE IN MALNUTRITION SiR.—Dr. McLeanstates that " the most important death in malnutrition are infection, treatable causes dehydration, potassium deficiency, and perhaps folic-acid deficiency ". He has, however, overlooked hypoglycxmia, which we believe is a relatively important cause of death.
a
of
combat low blood-sugars, most of our hypoglycsemic patients have died, possibly owing to irreversible cerebral damage. It has become evident that more active steps are necessary to prevent any long period of starvation in malnourished children, with consequent hope of reduction in the numbers dying from hypoglycaemia.
taken
to
Baragwanath Hospital, Johannesburg.
S. WAYBURNE.
PERITONITIS AFTER JEJUNAL BIOPSY WITH CROSBY CAPSULE
SIR,-In connection with the letter5 of Dr. Shackleton and Dr. Haas, we wish to report a case of peritonitis in an adult after the use of the Crosby capsule to obtain a jejunal mucosal biopsy specimen. Intestinal malabsorption was investigated in a 22-year-old who had
lifelong history of milk intolerance. A normal D-xylose absorption, and a normal jejunal mucosa on X-ray examination and by biopsy through a Rubin tube, were found at another hospital. Her ileum had been previously removed surgically because of an internal hernia.
woman
a
1. McLean, A. E. Lancet, 1962, ii, 1292. 2. Kahn, B. S. Afr. med. J. 1954, 28, 110. 3. Kahn, E., Wayburne, S. Proc. Nutr. Soc. S. Afr. 1960, 1, 21. 4. Slone, D., Taitz, L. S., Gilchrist, G. S. Brit. med. J. 1961, i, 32. 5. See Lancet, 1962, ii, 989.
a recent
peritonitis.
Peritonitis probably would not have arisen if this patient had not eaten. The supposition is that peristalsis and increased intraluminal pressure caused intestinal contents to escape through a minute perforation at the biopsy site. This hole was sealed by the time of operation. This perforation occurred in a young adult with a histologically normal small bowel. The reason for this perforation is not known, but the capsule has a large mucosal port (3-6 mm. diameter) and it is operated without manometric control. These factors might increase the
likelihood of
perforation.
Department of Medicine,
University of Colorado Medical Center, Denver 20, Colorado U.S.A.
JOHN E. STRUTHERS, Jr. WAYNE L. ATTWOOD FRED KERN, Jr.
ROLE OF CHLORIDE IN THE CORRECTION OF ALKALOSIS ASSOCIATED WITH POTASSIUM DEPLETION
SIR,-We have read with interest the communication of Dr. Aber and his colleagues. They found low or normal values of PC02 in cases of combined hypochlorxmic and hypokalaemic alkalosis. Commenting on their paper, Dr. 1.
Aber, G. M., Sampson, P. A., Whitehead, 1962, ii, 1028.
T.
P., Brooke, B. N. Lancet,
448
technique for measuring high PC02 values in combined hypochloraemic and hypokalaonic alkalosis. Fig. 2 shows cumulative electrolyte balances, electrolyte concentrations, and data about the acid-base equilibrium in a patient with obstruction of the pylorus by gastric carcinoma. On admission, the patient was hypokalxmic (plasma-potassium 2-5 mEq. per litre) and extremely hypochlorxmic (plasma-chloride 64 mEq. per litre). The blood pH and Pco2 values, measured with Astrup’s method, were 7-558 and 64 mm. Hg. In the course of correction of the hypochlorxmia with saline infusions the PC02 became normal (43 mm. Hg), but the potassium balance was only slightly positive. Mild hypokalaemia (plasma-potassium 3’2 mEq. per litre on the 8th day) as well as a pure metabolic alkalosis (blood pH 7-545) persisted. Gastrectomy was performed. Two weeks later, when the metabolic alkalosis had disappeared, the
plasma-potassium and chloride values were normal. These findings show that high Pcoz values can be measured in hypokalaemic alkalosis, using Astrup’s technique. Moreover, they show that by correcting the chloride depletion a high Pc02 in mixed hypochlorasmic and hypokalxmic alkalosis can disappear, in spite of persisting alkalosis and hypokalxmia. Fig. 1-Reconstructed pH-log Pcoa lines in Astrup’s using the data of Aber et al.
Department of Internal Medicine, Radboud Hospital, University of Nijmegen,
nomogram,
The Netherlands.
questions the validity of Astrup’s method3 of measuring Pco2 in the presence of potassium depletion.
P. W. C. KLOPPENBORG A. P. JANSEN.
Polak2
Using Aber’s data about blood pH, Pco2, and standard bicarbonate, we reconstructed pH-log Pco2 lines in Astrup’s nomogram. We were surprised at the slope of these lines in cases 1, 4, and 5 (fig. 1). With reference to Dr. Polak’s comment, we submit the following observation to show the suitability of Astrup’s 2. 3.
Polak, A. ibid. p. 1275. Astrup, P., Jørgensen, K., Andersen, O. S., Engel, K. ibid. 1960, i, 1035.
ATTEMPTED SUICIDE
SIR,-Dr. Asher (Feb. 16) questions whether everyone who attempts suicide must see a psychiatrist. Few would disagree that a general physician who has the experience gained from constant and prolonged acquaintance with these patients, and the necessary time to devote, may decide what to do. More important than the style of the doctor who sees the is that somebody should see an independent informant before the patient is interviewed. Here, a psychiatric social worker does this and it takes him half-an-hour or more. Time and again we found that we erred before we made this a rule. Patients keen to leave hospital often conceal crucial pieces of information relevant to their disposal. During the past few months we would otherwise have discharged, to care for their young families, two women, in ignorance that they had had to be restrained from infanticide on the day before admission. There are many other examples we could give. The immediate happenings of the overdose, elicited from a relative or sometimes only from a police or ambulance man, are As Professor Stengel points out (Feb. 2) we not sufficient. need to know all the patient’s circumstances relevant to the attempt. Armed with this knowledge the physician interviewing the patient knows what to look for and what to ask about. If he follows this course he is not likely to err, except on the side of caution; but if he does not he may never realise the mistakes he makes.
patient
Department of Psychological Medicine, Royal Infirmary, Edinburgh. "
SIR,-The " operative is surely, "Some of them
sentence
NEIL KESSEL. of Dr. Asher’s letter
justfed-up’ and seek a holiday from the tedium of existence by taking a big sleep, and not caring about the risk ". I have italicised the because this word just highlights the two possible of the either that to put your life sentence: implications into jeopardy simply because you are fed-up is trivial (if this is the meaning, I disagree on moral grounds); or that problems of this type do not need assiduous investigations and handling (if it means this, I disagree on medical grounds). Let, indeed, the general physician of Dr. Asher’s psychiatric inclinations himself handle the personality "
are
"
"
Fig. 2-A woman of 39 with pyloric obstruction. Cumulative electrolyte balances, plasma-electrolyte concentrations, values for blood pH, Pco., and standard bicarbonate during the correction of hypochloreemie hypokalactnic alkalosis.
"
"