- Email: [email protected]
TREATMENT OF INTESTINAL OBSTRUCTION.
1078 I visited the patient at her home two weeks later and found her well and happy and able to walk upstairs unaided, though the calf muscles and erectores spinae were still slightly stiff.
Summary. Dosage.-30-40 c.cm. in adults ; 12--20 c.cm. in children of about 12, adjusted according to the severity of individual cases. The doses in this series of 14 cases were too high, except in Case 2. SEQUELAE. 1. Rigidity of the back muscles is often present, due to irritation of the motor nerve roots, from the first to the seventh day of the injection. The decrease or disappearance of lockjaw is an indication of amelioration, though it is possible that carbolic may cause lockjaw through irritation of the fifth cranial nerve, when the seventh nerve will be simultaneously stimulated, as shown in Case 8 by slight tonic contraction of the facial and orbicularis oculi muscles-a tonic risus sardonicus. 2. A rash, varying in character and intensity, appears between the first and the seventh days and lasts from 4 to 14 days. It abates without treatment and should cause no anxiety. It may be due to overdose, but is probably produced by the elimination of carbolic by way of the skin. 3. Acute nephritis was present in Cases 1, 6, and 11, no doubt due to elimination of carbolic through the kidneys. This treatment should therefore not be given to patients with chronic renal disease, especially old people who have some impairment of the kidneys. However, Case 14, 60 years of age, got well without this complication. There were no late complications of the nervous system. The older cases, 2, 5, 8, 9, were traced to their homes in November, 1930. The school-boy , (Case 2) had passed his intermediate school examination. The Hindu (Case 5) was busy collecting grass for his cows and going his morning rounds in his cart with milk-bottles. The boy of 11 years in Case 8 had become an errand-boy. The chauffeur (Case 9) was driving his master prince to and from the barracks every day. The advantages of carbolic over serum are : (1) it is more certain in action : (2) one injection suffices ; (3) the cost is almost nil. The only disadvantage is the danger in chronic kidney disease.
TREATMENT OF INTESTINAL OBSTRUCTION. BY GAVIN MILLER,
M.SC., M.D. MCGILL,
DEMONSTRATOR IN MCGILL UNIVERSITY AND ASSOCIATE SURGEON TO THE ROYAL VICTORIA HOSPITAL, MONTREAL.
IT has been suggested that operation for the relief of small-bowel obstruction should be delayed until dehydration has been overcome, but it is necessary to review very carefully all the information available before making such a serious change. It is generally recognised that the number of hours elapsing between the onset of symptoms and the relief of small-bowel obstruction is directly proportional to the mortality percentage. Thus there will be a mortality-rate of about 30 per cent. among patients who have had symptoms of obstruction for 30 hours. While this. is a rough and somewhat inaccurate basis for prognosis, a review of published mortality statistics shows that. it is sufficiently correct for practical purposes. If each hour’s delay increases the risk of death by 1 per cent. it is evident that operation must not be delayed on any account unless the new therapeutic procedure can guarantee a lowered mortality in spite of the delay. As a result of the exhaustive study of small-bowel obstruction which has been carried on, mostly in America, during the past 15 years, it is now clearly recognised that such obstructions fall into two great groups : (1) simple obstruction without impairment of the blood-supply, and (2) strangulated obstruction with impairment of the blood-supply.
Most studies of small-bowel obstruction have been concerned only with the former group, and death has been definitely shown to be due in these cases to dehydration. In the strangulated type the vitality of the bowel wall is rapidly impaired, gangrene results, and death occurs through toxaemia or through perforation and peritonitis-as a rule, before there are, very marked changes in the levels of the bloodchlorides, carbon dioxide combining power and total non-protein nitrogen, and before dehydration can assume a
fatal
proportion.
Dehydration
in
Simple Obstruction.
In simple obstruction, as carried out experimentally, a different picture is seen. Here the few circulatory Conclusion. in wall do the bowel not lead to the rapid changes due to these factors. onset of Toxaemia the number of cases treated is as gangrene. Though yet small, I venture to form an opinion that carbolic plays a much less important role. The persistent acid given intrathecally is a specific remedy against loss of gastro-intestinal secretion so deprives the body tetanus. Out of 14 cases treated four died, but these of its normal ionic content, chiefly derived from sodium were severe cases, having reached the final stage of chloride, that water cannot be retained in the body and cardiac and respiratory failure, except Case 7 which, death ensues owing to dehydration. I think, died from uraemia due to the already infected Normally, several thousand cubic centimetres of to rather than from tetanus. seems be There gastro-intestinal secretions, rich in sodium and kidneys little doubt that the ten patients that recovered chloride, are poured into the stomach and upper part owed their lives to the carbolic treatment, for they of the small bowel every 24 hours. These fluids play were not of the mild variety that might recover their part in the digestion of food materials and are spontaneously. Any amount of serum which had reabsorbed in the lower part of the bowel. As fluid been given inadvertently was not sufficient to effect in the stomach and bowel is outside the body proper a cure. Besides, in no case had it been given intra- it is lost to the body until it is reabsorbed. By the thecally. The intrathecal carbolic treatment has been constant secretion and reabsorption of this great given without selection to all cases of tetanus volume of fluid and salt, the normal fluid metabolism admitted into the King Chulalongkorn Memorial of the body is maintained. The amount of water Hospital, since Jan. 26th, 1930 (Case 3), up to the imbibed only replaces that lost through perspiration, present time (end of 1930), with the exception of respiration, and excretions. two moribund cases of tetanus neonatorum. The When the small bowel is obstructed this endless recovery in Case 13 (tetanus neonatorum) was chain of secretion and reabsorption is broken. The secretion continues to be poured out, but it remarkable.
1079
beyond the obstruction to be reabsorbed. responds to the blockage with hyperperistalsis. The fluid is forced against the obstruction
Stewart.6 Animals with complete duodenal obstruction can be kept alive for six weeks or more provided that the lost sodium chloride can be restored and and a reverse current is formed, which carries the starvation prevented. fluid backwards and finally into the stomach, which fills up and eventually overflows. This causes the Simultaneous Treatment of Dehydration and of usual in the later so type Obstruction. regurgitant vomiting stages of obstruction, consisting of foul-smelling As death in simple obstruction is thus definitely greenish or yellowish material. As these secretions caused by dehydration, it is easy to see how the collect and stagnate, aerobic and anaerobic bacteria has arisen that, before the patient is suggestion rapidly grow, fermentation occurs, and so gas collects. to a serious operation, steps should be taken increasing the distension. It is this distension by exposed to overcome dehydration by the intravenous injection gas and fluid which makes X ray diagnosis so valuable of sodium chloride solution. This suggestion ought in these cases. If a patient suspected of having to be worded differently. By all means give sodium intestinal obstruction is X rayed in the erect position chloride solution, either isotonic or hypertonic, but or lying on the side, and the plate shows a distended this procedure should not delay the operation by one small bowel with fluid levels, a diagnosis of intestinal minute. It has been shown that dehydration is the obstruction can be made. The first vomiting which cause of death only in simple obstruction. This work occurs in intestinal obstruction is reflex and empties has only been carried out experimentally on dogs. the stomach. After this the vomitus consists of The majority of cases of small-bowel obstruction gastro-intestinal secretions rich in sodium chloride. foundgreat at operation are of the strangulated variety. As reabsorption of this sodium chloride is prevented, This applies to all those cases caused by hernisa, the sum total of this salt in the body progressively twisted Meckel’s diverticulse, and, as a rule, diminishes. Any reserve stores which may exist in i volvulus, those arising from adhesions. Furthermore, except in I the skin are soon exhausted. i cases where strangulated herniae can be recognised, It is generally accepted that the total fluid in the it is impossible to differentiate between the body is maintained by its total ionic content which, simplequite and the strangulated varieties before operation. in the case of blood-plasma and interstitial fluid, It is therefore imperative to treat for the more consists practically wholly of ionised sodium chloride. serious possibility-namely, strangulated obstruction. With the loss of sodium chloride by vomiting the Death in those cases occurs early, before any great ability of the body to maintain its fluid is likewise lost degree of dehydration has occurred, and is due to and dehydration rapidly ensues. It is often supposed toxsemia. will save them. Only early operation that the progressive fall of plasma chloride, so typical When discussing the clinical application of experiof intestinal obstruction, is the result of this dehydramental findings, consideration must also be given totion and shows the degree of dehydration present. This is not strictly accurate. The chloride is lost, as the important question of whether the results of simple obstruction in dogs are exactly similar, in all hydrochloric acid, in the stomach secretion. This the physiological and pathological effects, to those in chloride radical is replaced by COradical in the blood- I I have found less distension and less marked man. plasma. There is consequently a marked increase I in the carbon dioxide combining power in the plasma, changes in the bowel walls after obstruction in dog& than is usually present at operation on clinical cases. giving a severe alkalosis. The total ionic content of At operation the human bowel is often greatly the plasma, however, is not necessarily changed. distended, very dark purple in colour from prolonged It is thus evident that both acid and base radicals and very thin. It has been shown that congestion, must be lost from the blood-plasma before the total ionic content falls, and it is unable to retain its normal great distension impairs the circulation in the bowel wall by obstructing the venous return. If this be so, amount of fluid. Gamble and Rosssuggested that dehydration is it follows that even in simple obstruction in man the due to the loss of sodium. Sodium determinations factor of togaemia due to impaired blood-supply of the bowel wall cannot altogether be eliminated. Personally, on the blood-plasma show a slight but progressive diminution in these cases. The percentage of sodium I do not believe that human beings could be kept alive falls, however, because the total ionic content has for a month solely by means of the intravenous been increased in other directions. The total non- injection of salt solution, though dogs can. A danger which must be recognised in the operative protein nitrogen and urea nitrogen increase greatly, and this increase may be, to some extent, ionised, release of a mechanical obstruction is that, with the thus increasing the total ionic content. If no free relief of distension, the venous return is permitted. hydrochloric acid were lost in the stomach secretion After several hours of venous stasis there must be a and waste products did not accumulate in the blood, great collection of histamine-like end-products from it would be quite possible to have a very marked metabolism and from damaged bowel which are degree of dehydration with no change in sodium and suddenly returned into the circulation. This event chloride blood-plasma percentage determinations. must accentuate any symptoms of shock which are If, however, the total sodium chloride in the plasma already present. I believe this to be the cause of of the body could be estimated, a very marked decrease death in those cases of late obstruction which die a would be shown. As I have demonstrated elsewhere,2 few hours after operative interference, although the the total ionic content of intracellular fluid is made up operation has been relatively simple. It seems, therefore, self-evident that to delay largely of potassium and phosphoric ions, which are not lost in the gastro-intestinal secretion, and thus the operation until dehydration can be overcome by intracellular fluid is not disturbed in dehydration to means of intravenous saline therapy, checked by any great degree. Dehydration affects mainly the observation of the blood chemistry values, would be blood-plasma and the interstitial fluid. That this very unwise. It could only be of use in a very small dehydration is the cause of death in simple small- percentage of cases of simple small-bowel obstruction, bowel obstruction has been definitely shown by many and these cases cannot be differentiated from the investigators-Hartwell and Hognet,3 Haden and strangulated variety before operation. The rule of Orr,4Gamble and McIver,5Armour, Mitchell, and immediate laparotomy for intestinal obstruction cannot pass
The bowel
I
I I,
I
1080
two
must be adhered to, and it must be constantly borne in mind that the mortality in these cases is directly proportional to the number of hours occurring between onset of symptoms and relief of obstruction. In cases where the diagnosis is in doubt, the surgeon should never spend time in " masterly inactivity" A simple or in observation of the further progress. antero-posterior X ray plate will confirm the diagnosis in ten minutes. The patient should proceed directly from the X ray room to the operating room, where 1000 c.cm. of normal sodium chloride solution can be injected intravenously after the anaesthetic has started, while the patient is being prepared for the operation. The injection can, of course, be continued during the operation. If desired, 15 g. of sodium chloride may be added to the normal saline solution
hasten the return of blood chlorides to normal. a procedure will reduce the unfortunately large I and, I believe, unnecessary mortality which occurs in so many hospitals from small-bowel intestinal obstruction.
Such
BIBLIOGRAPHY. Jour. Clin. Invest., 1925, i., 403. Miller, G. G.: Edin. Med. Jour. Jan., 1931, p. 47. Hartwell, J. A., and Hognet, J. P.: Jour. Amer. Med. Assoc., 1912, lxxxii., 59. Haden, R. L., and Orr, T. G. : Jour. Exp. Med., 1923, xxxviii., 55; Jour. Amer. Med. Assoc., 1928, xci., 20. Gamble, and McIver, M. A. : Ibid., p. 589. Armour, J. C., Brown, T. G., Dunlop, D. M., Mitchell, T. C., Searls, H. H., and Stewart, C. P.: Brit. Jour. Surg., Jan., 1931, p. 467. Cooper, H. S. F.: Arch. Surg., 1928, xvii., 918 (for complete bibliography).
1. Gamble, J. 2. 3.
4. 5. 6.
7.
L., and Ross, S. G.:
CLINICAL AND LABORATORY NOTES BLOOD-PLATELETS IN PERNICIOUS ANÆMIA.
,
I
Treatment was carried out with a commercial liver extract and whole liver on alternate days ; in addition dilute HCI to the extent of 20 minims four times daily was given, before meals. The first observation on the platelets was made on
Oct. 28th, five days from the commencement of liver treatment. They were found to number 91,000 per c.mm. The blood at this time showed the height of the reticulocyte crisis, the reticulocytes forming 11-6 per cent. of the red cells, a total of 211,120 per c.mm. Four days later the platelets had risen to 293,000 per c.mm. Thereafter their numbers fluctuated considerably but never again fell so low as on the first examination. The behaviour of platelets, red cells, and reticulocytes was as follows :-
BY S. C. DYKE, D.M. OXF., M.R.C.P. LOND., CONSULTING PATHOLOGIST TO THE ROYAL HOSPITAL,
WOLVERHAMPTON; AND
W. STEWART, M.B. GLASG., ASSISTANT PATHOLOGIST TO THE HOSPITAL.
Reticulocytes.
Red cells (in
Total and
Platelets. thousands). . OBSERVATIONS upon the blood-platelets in perper cent. nicious ansemia are scanty and to some extent contra- Oct. 28th.... 1,820 211,120 (5’0) 91,000 " 31st.... 1,820 293,720 dictory. As the result of the study of the blood in Nov. 4th 2,010 271,230(4-6) ..... 118,590 None seen..... 187,110 cases under treatment with liver one of us (S. C. D.) 2,970 llth 18th 3,490 320,000 gained the impression that these elements of the blood were scanty during the relapse phase but tended to CASE 2 -Female, aged 55. History of anorexia and increase in numbers with improvement of the blood constipation with pain in lumbar region for past seven Loss of last two years, vomiting last two picture. This impression was placed upon record 1years. I weeks. Admittedweight to surgical ward as case of cholecystitis. together with the statement that the platelets may Jaundiced, anaemic. The blood-picture on March 13th was in cases of pernicious anaemia be so low as 150,000 Hb., 38 per cent. ; red cells, 1,370,000 per c.mm. ; white cells, i This statement was not based upon10,000 per c.mm. ; and colour-index, 1-42. The percentages per c.mm. white cells were polymorphs, 39 ; lymphocytes, 55 ; I careful and systematic observation, which since then of and monocytes, 6 ; no eosinophils or basophils were seen. has shown that during the relapse phase the platelets There was considerable anisocytosis of red cells and the occur in far fewer numbers than then stated, and, mean diameter of red cells was 8’5/. Fractional test-meal showed complete absence of free HCl furthermore, that they actually do increase to normal from all specimens. The progress of the case was as follows :— under liver therapy. ......
....
-
......
....
....
......
...
......
......
"
....
"
I
I:
Red cells fir.
Red thousands.). cells (m
Case Histories.
Reticulocytes.
Platelets.
Total and per cent.
CASE I.-Female, aged 36. Admitted Oct. 15th, 1930, with March 13th.... 124,600 1,370 41.000 (3’0) history of weakness and lassitude extending over two years ;I 20th .... 132,400 1,920 48,000 (2-5) more recently tingling, numbness, and loss of power in legs, I 25th .... 175,930 2,410 16,000 (0’7) from of loss Occasional of attacks hospital. Discharged anorexia, and weight. diarrhoea. Absent..... 243,256 4,250 On admission a pale, asthenic, and rather wasted subject, Sept. 15th .... mentally very depressed ; tendon reflexes present and normal i CASE 3.-Female, aged 63. History of weakness and in legs and arms, plantar reflex flexor ; considerable disturbshortness of breath for three months ; numbness and weakance of sensation in legs and to a less extent in arms ; almost complete loss of power in right leg and movement of left ness of legs for past month. On admission skin lemon-yellow in colour ; spleen palpable, no tendon reflexes obtained in any leg very much impaired. ....
"
....
"
....
....
....
....
....
A fractional test-meal taken shortly after admission showed complete absence of free hydrochloric acid ; this examination was repeated two weeks after the commencement of treatment having been immediately preceded by the injection of half a milligramme of histamine ; free HCI remained absent. The blood-picture at the commencement of treatment was : haemoglobin (Hb.), 38 per cent ; red cells, 1,510,000 per c.mm. ; white cells, 3400 ; colour-index, 1-26 ; volume-index, 1-5. The percentages of white cells were : polymorphs, 57 ; lymphocytes, 41 ; monocytes, 2. No eosinophils or basophils were seen. There was some anisocytosis and poikilocytosis of red cells, with many nucleated red cells. The mean diameter of red cells (halo The van den Bergh reaction was direct method) was 8-3. negative ; indirect positive, and the bilirubin 14 mg. per litre. 1 Liver in the Treatment of Pernicious and other Anæmias,
London, 1930.
limb. Plantar reflex flexor. The blood-picture on Feb. 4th, 1930, at the commencement of treatment was : Hb., 34 per cent; red cells, 1,260,000 per c.mm. ; white cells, 2100 ; colour-index, 135 ; reticulocytes, 1-3 per cent. of red cells ; and platelets, 22,800 per c.mm. The percentages of white cells were : polymorphs, 47 ; lymphocytes, 45 ; monocytes, 5 ; and eosinophils, 3. No basophils were seen. There was marked anisocytosis and poikilocytosis of red cells and the van den Bergh reaction was negative direct, indirect positive, and the bilirubin 45 mg. per litre. A fractional test-meal showed complete absence of free HO]. The patient was treated for two weeks on a German preparation of dried stomach upon which she made no progress whatever. At the end of this time the red cells remained at their original level, there had been no increase in the reticulocytes, and the platelets had fallen to 43,000 On Feb. 19th the patient was put on Ventriculin per c.mm.
(Parke Davis),
10
teaspoonfuls daily.
The
subsequent
Summary. Dosage.-30-40 c.cm. in adults ; 12--20 c.cm. in children of about 12, adjusted according to the severity of individual cases. The doses in this series of 14 cases were too high, except in Case 2. SEQUELAE. 1. Rigidity of the back muscles is often present, due to irritation of the motor nerve roots, from the first to the seventh day of the injection. The decrease or disappearance of lockjaw is an indication of amelioration, though it is possible that carbolic may cause lockjaw through irritation of the fifth cranial nerve, when the seventh nerve will be simultaneously stimulated, as shown in Case 8 by slight tonic contraction of the facial and orbicularis oculi muscles-a tonic risus sardonicus. 2. A rash, varying in character and intensity, appears between the first and the seventh days and lasts from 4 to 14 days. It abates without treatment and should cause no anxiety. It may be due to overdose, but is probably produced by the elimination of carbolic by way of the skin. 3. Acute nephritis was present in Cases 1, 6, and 11, no doubt due to elimination of carbolic through the kidneys. This treatment should therefore not be given to patients with chronic renal disease, especially old people who have some impairment of the kidneys. However, Case 14, 60 years of age, got well without this complication. There were no late complications of the nervous system. The older cases, 2, 5, 8, 9, were traced to their homes in November, 1930. The school-boy , (Case 2) had passed his intermediate school examination. The Hindu (Case 5) was busy collecting grass for his cows and going his morning rounds in his cart with milk-bottles. The boy of 11 years in Case 8 had become an errand-boy. The chauffeur (Case 9) was driving his master prince to and from the barracks every day. The advantages of carbolic over serum are : (1) it is more certain in action : (2) one injection suffices ; (3) the cost is almost nil. The only disadvantage is the danger in chronic kidney disease.
TREATMENT OF INTESTINAL OBSTRUCTION. BY GAVIN MILLER,
M.SC., M.D. MCGILL,
DEMONSTRATOR IN MCGILL UNIVERSITY AND ASSOCIATE SURGEON TO THE ROYAL VICTORIA HOSPITAL, MONTREAL.
IT has been suggested that operation for the relief of small-bowel obstruction should be delayed until dehydration has been overcome, but it is necessary to review very carefully all the information available before making such a serious change. It is generally recognised that the number of hours elapsing between the onset of symptoms and the relief of small-bowel obstruction is directly proportional to the mortality percentage. Thus there will be a mortality-rate of about 30 per cent. among patients who have had symptoms of obstruction for 30 hours. While this. is a rough and somewhat inaccurate basis for prognosis, a review of published mortality statistics shows that. it is sufficiently correct for practical purposes. If each hour’s delay increases the risk of death by 1 per cent. it is evident that operation must not be delayed on any account unless the new therapeutic procedure can guarantee a lowered mortality in spite of the delay. As a result of the exhaustive study of small-bowel obstruction which has been carried on, mostly in America, during the past 15 years, it is now clearly recognised that such obstructions fall into two great groups : (1) simple obstruction without impairment of the blood-supply, and (2) strangulated obstruction with impairment of the blood-supply.
Most studies of small-bowel obstruction have been concerned only with the former group, and death has been definitely shown to be due in these cases to dehydration. In the strangulated type the vitality of the bowel wall is rapidly impaired, gangrene results, and death occurs through toxaemia or through perforation and peritonitis-as a rule, before there are, very marked changes in the levels of the bloodchlorides, carbon dioxide combining power and total non-protein nitrogen, and before dehydration can assume a
fatal
proportion.
Dehydration
in
Simple Obstruction.
In simple obstruction, as carried out experimentally, a different picture is seen. Here the few circulatory Conclusion. in wall do the bowel not lead to the rapid changes due to these factors. onset of Toxaemia the number of cases treated is as gangrene. Though yet small, I venture to form an opinion that carbolic plays a much less important role. The persistent acid given intrathecally is a specific remedy against loss of gastro-intestinal secretion so deprives the body tetanus. Out of 14 cases treated four died, but these of its normal ionic content, chiefly derived from sodium were severe cases, having reached the final stage of chloride, that water cannot be retained in the body and cardiac and respiratory failure, except Case 7 which, death ensues owing to dehydration. I think, died from uraemia due to the already infected Normally, several thousand cubic centimetres of to rather than from tetanus. seems be There gastro-intestinal secretions, rich in sodium and kidneys little doubt that the ten patients that recovered chloride, are poured into the stomach and upper part owed their lives to the carbolic treatment, for they of the small bowel every 24 hours. These fluids play were not of the mild variety that might recover their part in the digestion of food materials and are spontaneously. Any amount of serum which had reabsorbed in the lower part of the bowel. As fluid been given inadvertently was not sufficient to effect in the stomach and bowel is outside the body proper a cure. Besides, in no case had it been given intra- it is lost to the body until it is reabsorbed. By the thecally. The intrathecal carbolic treatment has been constant secretion and reabsorption of this great given without selection to all cases of tetanus volume of fluid and salt, the normal fluid metabolism admitted into the King Chulalongkorn Memorial of the body is maintained. The amount of water Hospital, since Jan. 26th, 1930 (Case 3), up to the imbibed only replaces that lost through perspiration, present time (end of 1930), with the exception of respiration, and excretions. two moribund cases of tetanus neonatorum. The When the small bowel is obstructed this endless recovery in Case 13 (tetanus neonatorum) was chain of secretion and reabsorption is broken. The secretion continues to be poured out, but it remarkable.
1079
beyond the obstruction to be reabsorbed. responds to the blockage with hyperperistalsis. The fluid is forced against the obstruction
Stewart.6 Animals with complete duodenal obstruction can be kept alive for six weeks or more provided that the lost sodium chloride can be restored and and a reverse current is formed, which carries the starvation prevented. fluid backwards and finally into the stomach, which fills up and eventually overflows. This causes the Simultaneous Treatment of Dehydration and of usual in the later so type Obstruction. regurgitant vomiting stages of obstruction, consisting of foul-smelling As death in simple obstruction is thus definitely greenish or yellowish material. As these secretions caused by dehydration, it is easy to see how the collect and stagnate, aerobic and anaerobic bacteria has arisen that, before the patient is suggestion rapidly grow, fermentation occurs, and so gas collects. to a serious operation, steps should be taken increasing the distension. It is this distension by exposed to overcome dehydration by the intravenous injection gas and fluid which makes X ray diagnosis so valuable of sodium chloride solution. This suggestion ought in these cases. If a patient suspected of having to be worded differently. By all means give sodium intestinal obstruction is X rayed in the erect position chloride solution, either isotonic or hypertonic, but or lying on the side, and the plate shows a distended this procedure should not delay the operation by one small bowel with fluid levels, a diagnosis of intestinal minute. It has been shown that dehydration is the obstruction can be made. The first vomiting which cause of death only in simple obstruction. This work occurs in intestinal obstruction is reflex and empties has only been carried out experimentally on dogs. the stomach. After this the vomitus consists of The majority of cases of small-bowel obstruction gastro-intestinal secretions rich in sodium chloride. foundgreat at operation are of the strangulated variety. As reabsorption of this sodium chloride is prevented, This applies to all those cases caused by hernisa, the sum total of this salt in the body progressively twisted Meckel’s diverticulse, and, as a rule, diminishes. Any reserve stores which may exist in i volvulus, those arising from adhesions. Furthermore, except in I the skin are soon exhausted. i cases where strangulated herniae can be recognised, It is generally accepted that the total fluid in the it is impossible to differentiate between the body is maintained by its total ionic content which, simplequite and the strangulated varieties before operation. in the case of blood-plasma and interstitial fluid, It is therefore imperative to treat for the more consists practically wholly of ionised sodium chloride. serious possibility-namely, strangulated obstruction. With the loss of sodium chloride by vomiting the Death in those cases occurs early, before any great ability of the body to maintain its fluid is likewise lost degree of dehydration has occurred, and is due to and dehydration rapidly ensues. It is often supposed toxsemia. will save them. Only early operation that the progressive fall of plasma chloride, so typical When discussing the clinical application of experiof intestinal obstruction, is the result of this dehydramental findings, consideration must also be given totion and shows the degree of dehydration present. This is not strictly accurate. The chloride is lost, as the important question of whether the results of simple obstruction in dogs are exactly similar, in all hydrochloric acid, in the stomach secretion. This the physiological and pathological effects, to those in chloride radical is replaced by COradical in the blood- I I have found less distension and less marked man. plasma. There is consequently a marked increase I in the carbon dioxide combining power in the plasma, changes in the bowel walls after obstruction in dog& than is usually present at operation on clinical cases. giving a severe alkalosis. The total ionic content of At operation the human bowel is often greatly the plasma, however, is not necessarily changed. distended, very dark purple in colour from prolonged It is thus evident that both acid and base radicals and very thin. It has been shown that congestion, must be lost from the blood-plasma before the total ionic content falls, and it is unable to retain its normal great distension impairs the circulation in the bowel wall by obstructing the venous return. If this be so, amount of fluid. Gamble and Rosssuggested that dehydration is it follows that even in simple obstruction in man the due to the loss of sodium. Sodium determinations factor of togaemia due to impaired blood-supply of the bowel wall cannot altogether be eliminated. Personally, on the blood-plasma show a slight but progressive diminution in these cases. The percentage of sodium I do not believe that human beings could be kept alive falls, however, because the total ionic content has for a month solely by means of the intravenous been increased in other directions. The total non- injection of salt solution, though dogs can. A danger which must be recognised in the operative protein nitrogen and urea nitrogen increase greatly, and this increase may be, to some extent, ionised, release of a mechanical obstruction is that, with the thus increasing the total ionic content. If no free relief of distension, the venous return is permitted. hydrochloric acid were lost in the stomach secretion After several hours of venous stasis there must be a and waste products did not accumulate in the blood, great collection of histamine-like end-products from it would be quite possible to have a very marked metabolism and from damaged bowel which are degree of dehydration with no change in sodium and suddenly returned into the circulation. This event chloride blood-plasma percentage determinations. must accentuate any symptoms of shock which are If, however, the total sodium chloride in the plasma already present. I believe this to be the cause of of the body could be estimated, a very marked decrease death in those cases of late obstruction which die a would be shown. As I have demonstrated elsewhere,2 few hours after operative interference, although the the total ionic content of intracellular fluid is made up operation has been relatively simple. It seems, therefore, self-evident that to delay largely of potassium and phosphoric ions, which are not lost in the gastro-intestinal secretion, and thus the operation until dehydration can be overcome by intracellular fluid is not disturbed in dehydration to means of intravenous saline therapy, checked by any great degree. Dehydration affects mainly the observation of the blood chemistry values, would be blood-plasma and the interstitial fluid. That this very unwise. It could only be of use in a very small dehydration is the cause of death in simple small- percentage of cases of simple small-bowel obstruction, bowel obstruction has been definitely shown by many and these cases cannot be differentiated from the investigators-Hartwell and Hognet,3 Haden and strangulated variety before operation. The rule of Orr,4Gamble and McIver,5Armour, Mitchell, and immediate laparotomy for intestinal obstruction cannot pass
The bowel
I
I I,
I
1080
two
must be adhered to, and it must be constantly borne in mind that the mortality in these cases is directly proportional to the number of hours occurring between onset of symptoms and relief of obstruction. In cases where the diagnosis is in doubt, the surgeon should never spend time in " masterly inactivity" A simple or in observation of the further progress. antero-posterior X ray plate will confirm the diagnosis in ten minutes. The patient should proceed directly from the X ray room to the operating room, where 1000 c.cm. of normal sodium chloride solution can be injected intravenously after the anaesthetic has started, while the patient is being prepared for the operation. The injection can, of course, be continued during the operation. If desired, 15 g. of sodium chloride may be added to the normal saline solution
hasten the return of blood chlorides to normal. a procedure will reduce the unfortunately large I and, I believe, unnecessary mortality which occurs in so many hospitals from small-bowel intestinal obstruction.
Such
BIBLIOGRAPHY. Jour. Clin. Invest., 1925, i., 403. Miller, G. G.: Edin. Med. Jour. Jan., 1931, p. 47. Hartwell, J. A., and Hognet, J. P.: Jour. Amer. Med. Assoc., 1912, lxxxii., 59. Haden, R. L., and Orr, T. G. : Jour. Exp. Med., 1923, xxxviii., 55; Jour. Amer. Med. Assoc., 1928, xci., 20. Gamble, and McIver, M. A. : Ibid., p. 589. Armour, J. C., Brown, T. G., Dunlop, D. M., Mitchell, T. C., Searls, H. H., and Stewart, C. P.: Brit. Jour. Surg., Jan., 1931, p. 467. Cooper, H. S. F.: Arch. Surg., 1928, xvii., 918 (for complete bibliography).
1. Gamble, J. 2. 3.
4. 5. 6.
7.
L., and Ross, S. G.:
CLINICAL AND LABORATORY NOTES BLOOD-PLATELETS IN PERNICIOUS ANÆMIA.
,
I
Treatment was carried out with a commercial liver extract and whole liver on alternate days ; in addition dilute HCI to the extent of 20 minims four times daily was given, before meals. The first observation on the platelets was made on
Oct. 28th, five days from the commencement of liver treatment. They were found to number 91,000 per c.mm. The blood at this time showed the height of the reticulocyte crisis, the reticulocytes forming 11-6 per cent. of the red cells, a total of 211,120 per c.mm. Four days later the platelets had risen to 293,000 per c.mm. Thereafter their numbers fluctuated considerably but never again fell so low as on the first examination. The behaviour of platelets, red cells, and reticulocytes was as follows :-
BY S. C. DYKE, D.M. OXF., M.R.C.P. LOND., CONSULTING PATHOLOGIST TO THE ROYAL HOSPITAL,
WOLVERHAMPTON; AND
W. STEWART, M.B. GLASG., ASSISTANT PATHOLOGIST TO THE HOSPITAL.
Reticulocytes.
Red cells (in
Total and
Platelets. thousands). . OBSERVATIONS upon the blood-platelets in perper cent. nicious ansemia are scanty and to some extent contra- Oct. 28th.... 1,820 211,120 (5’0) 91,000 " 31st.... 1,820 293,720 dictory. As the result of the study of the blood in Nov. 4th 2,010 271,230(4-6) ..... 118,590 None seen..... 187,110 cases under treatment with liver one of us (S. C. D.) 2,970 llth 18th 3,490 320,000 gained the impression that these elements of the blood were scanty during the relapse phase but tended to CASE 2 -Female, aged 55. History of anorexia and increase in numbers with improvement of the blood constipation with pain in lumbar region for past seven Loss of last two years, vomiting last two picture. This impression was placed upon record 1years. I weeks. Admittedweight to surgical ward as case of cholecystitis. together with the statement that the platelets may Jaundiced, anaemic. The blood-picture on March 13th was in cases of pernicious anaemia be so low as 150,000 Hb., 38 per cent. ; red cells, 1,370,000 per c.mm. ; white cells, i This statement was not based upon10,000 per c.mm. ; and colour-index, 1-42. The percentages per c.mm. white cells were polymorphs, 39 ; lymphocytes, 55 ; I careful and systematic observation, which since then of and monocytes, 6 ; no eosinophils or basophils were seen. has shown that during the relapse phase the platelets There was considerable anisocytosis of red cells and the occur in far fewer numbers than then stated, and, mean diameter of red cells was 8’5/. Fractional test-meal showed complete absence of free HCl furthermore, that they actually do increase to normal from all specimens. The progress of the case was as follows :— under liver therapy. ......
....
-
......
....
....
......
...
......
......
"
....
"
I
I:
Red cells fir.
Red thousands.). cells (m
Case Histories.
Reticulocytes.
Platelets.
Total and per cent.
CASE I.-Female, aged 36. Admitted Oct. 15th, 1930, with March 13th.... 124,600 1,370 41.000 (3’0) history of weakness and lassitude extending over two years ;I 20th .... 132,400 1,920 48,000 (2-5) more recently tingling, numbness, and loss of power in legs, I 25th .... 175,930 2,410 16,000 (0’7) from of loss Occasional of attacks hospital. Discharged anorexia, and weight. diarrhoea. Absent..... 243,256 4,250 On admission a pale, asthenic, and rather wasted subject, Sept. 15th .... mentally very depressed ; tendon reflexes present and normal i CASE 3.-Female, aged 63. History of weakness and in legs and arms, plantar reflex flexor ; considerable disturbshortness of breath for three months ; numbness and weakance of sensation in legs and to a less extent in arms ; almost complete loss of power in right leg and movement of left ness of legs for past month. On admission skin lemon-yellow in colour ; spleen palpable, no tendon reflexes obtained in any leg very much impaired. ....
"
....
"
....
....
....
....
....
A fractional test-meal taken shortly after admission showed complete absence of free hydrochloric acid ; this examination was repeated two weeks after the commencement of treatment having been immediately preceded by the injection of half a milligramme of histamine ; free HCI remained absent. The blood-picture at the commencement of treatment was : haemoglobin (Hb.), 38 per cent ; red cells, 1,510,000 per c.mm. ; white cells, 3400 ; colour-index, 1-26 ; volume-index, 1-5. The percentages of white cells were : polymorphs, 57 ; lymphocytes, 41 ; monocytes, 2. No eosinophils or basophils were seen. There was some anisocytosis and poikilocytosis of red cells, with many nucleated red cells. The mean diameter of red cells (halo The van den Bergh reaction was direct method) was 8-3. negative ; indirect positive, and the bilirubin 14 mg. per litre. 1 Liver in the Treatment of Pernicious and other Anæmias,
London, 1930.
limb. Plantar reflex flexor. The blood-picture on Feb. 4th, 1930, at the commencement of treatment was : Hb., 34 per cent; red cells, 1,260,000 per c.mm. ; white cells, 2100 ; colour-index, 135 ; reticulocytes, 1-3 per cent. of red cells ; and platelets, 22,800 per c.mm. The percentages of white cells were : polymorphs, 47 ; lymphocytes, 45 ; monocytes, 5 ; and eosinophils, 3. No basophils were seen. There was marked anisocytosis and poikilocytosis of red cells and the van den Bergh reaction was negative direct, indirect positive, and the bilirubin 45 mg. per litre. A fractional test-meal showed complete absence of free HO]. The patient was treated for two weeks on a German preparation of dried stomach upon which she made no progress whatever. At the end of this time the red cells remained at their original level, there had been no increase in the reticulocytes, and the platelets had fallen to 43,000 On Feb. 19th the patient was put on Ventriculin per c.mm.
(Parke Davis),
10
teaspoonfuls daily.
The
subsequent