*> x,1936 A lDHESIONIS OF JOI TS- AND glJ oAL -929 perfectly reduced by operation, t he wound m a y heal with- o u t obvious infection, a n d passive movement and manipu- lation m a y be avoided i n a blameless after-treatment, a n d yet, i f wire i s used f o r internal fixation, there i s usually permanent limitation o f extension movement. T he wire i s associated with a low-grade inflammatory reaction, a n d t h e continued irritative serofibrinous exudation gives rise t o periarticular adhesion formation which i s particularly resistant. I n these fractures it is quite unnecessary to u se anything stronger than catgut, which absorbs s o rapidly that i t does n o t give rise t o adhesion formation. Similarly i n th e replacement o f epicondylar fragments t o t h e humerus, o f malleolar fragments t o t h e tibia, an d i n t h e repair o f comminuted fractures of t h e lower e n d o f t h e humerus and upper e n d o f t h e tibia, plates, screws, an d wire should always be avoided. T he rustless and stailnless metals recently introduced produce less reaction than other metals. Nevertheless, even these metals should b e used with caution, because some reaction does occur after tw o or three months. I n fractures of t h e neck o f t h e femur t h e effect o f a stainless steel nail i s minimized b y i t s distance from periarticular tissues. Even so, it appears advisable t o remove t h e nail i n all cases a s soon a s t h e fracture i s firmly united. Conclusion I would repeat, then, that fractures should b e perfectly immobilized b y complete fixation of adjacent joints, s o that active movement o f distant joints m ay b e practised painlessly. Patients must b e definitely instructed i n joint mobilization; briefly, a s follows: Colles s fracture: Fix wrist; actively move fingers, elbow, an d shoulder. Fractured shafts o f t h e radius a n d ulna: Fix elbow a n d wrist actively move fingers an d shoulder. Fractures of t h e elbow: F i x elbow actively move fingers, wrist, an d shoulder. Fractured shafts o f t h e humerus a n d shoulder: F i x shoulder an d elbow actively move wrist an d fingers. Pott s fracture: F x ankle actively move toes, knee, an d hip. Fractured shafts o f t h e tibia an d fibula: F i x ankle an d knee actively move toes an d hip. Fractured shaft of femur: F i x h i p an d knee actively move ankle and toes. neck o f femur (with nail): Actively move hip, knee, ankle, an d toes. Summary 1. Joint stiffness after injury i s d ue t o t he adhesion o f capsular plications, an d this m a y result from t h e organ- ization o f a n y i n t h e periarticular tissues. 2 . T h e adhesions o f immobilization, uncomplicated b y other factors, a r e temporary, an d recover b y t h e patient s o w n exercise. 3 . T h e factors which convert the recoverable stiffness o f injured immobilized joints into irrecoverable stiffness a r e those responsible f o r a continued o r repeated serofibrinous exudation: a ) disuse with continued venous stasis; ( b ) recurrent oedema; c ) repeated trauma o f passive stretching; (d) continued infection near a joint and irrita- tion o f foreign bodies near a joint. 4 . Fractures should S~ e perfectly immobilized b y com- plete fixation o f adjacent joints, s o that active movements o f distant joints m a y b e practised painlessly. REFERENCES 1 British Medical Journzal, 1932, i 542. 2 Ibid., 1932, i 1073. Supplement, Britsh Medical Journal7, 1935, i 5 3 . British Medica.l Jornal. 1935, a , 616. Ibid, 1923, i 135; 1933, i , 391. Ibid., 1933, i, 2 4 7 ; 1933, i , 34o. 7 Lan.cet, 1932, ii , 1217. Proc. Rov. Soc; Med., 1930, xxiii, Sect. Orthop., 2 3 . British -Mcdcal Journzal, 193 1, i i 1019. TREATMENT O F PARALYTIC ILEUS BY R. L . HOLT, F.R.C.S. HONORARY ASSISTANT SURGEON CHRISTIE IIOSPITAL; CHIEF ASSISTANT, SURGICAL UNIT, MIANCHESTER ROYAL INFIRIMARY Th e object o f this paper i s to outline a treatment o f paralytic ileus which I have used a s a routine during t h e past t w o years with consistently good results. I n t h e past a variety o f therapeutic measures have been recommended i n t h e treatment o f this condition and many o f them have enjoyed a certain measure o f success. B u t paralytic ileus still remains o n e of the most harassing post-operative complications which t h e surgeon i s called upon t o treat. Th e condition begins a s a n inhibition o f intestinal tone a n d motility as a result o f injury o f t h e neuro-muscular mechanism or o f inhibitory impulses from t h e spinal cord an d coeliac plexus. I n t h e early stages t h e intestinal muscle i s capable o f contracting if suitably stimulated. In the later stages, perhaps a s a result o f overstretching and circulatory disturbances, t h e intestinal muscle loses t s contractile power and does n o t readily regain i t . T h e common method o f treatment i s t o u se some drug o r measure which under normal conditions will augment intestinal peristalsis. Many cases o f intestinal paresis m a y be resolved b y t h e timely use o f such drugs a s pituitrin, eserine, acetylcholine, etc., b u t this i s n o t surprising when t h e many grades i n which this condition occurs a r e considered. T h e fact remains that many other cases d o not respond t o stimulant measures, an d frequently t h e conclusion cannot b e escaped that t h e continued us e o f such measures has an il l effect o n t h e progress o f t h e patient. The too literal adoption o f t h e o l d dictum G e t t h e bowels open a nd t h e patient will live, which h a s long formed t h e basis o f t h e treatment o f paralytic ileus, i s likely t o kill more patients than it will save. Physiopathology o f Paralytic lleus- Whatever t he cause o f t h e condition, t he essential clinical features a r e a distension o f t h e intestinal tract -usually most marked i n t h e small intestine-and a complete o r almost complete absence o f intestinal move- ments. Vomiting i s n o t s o marked a symptom i n paralytic ileus a s i n mechanical obstruction, and unless t h e patient ha s been given large amounts o f fluid by mouth th e intestinal distension i n paralytic ileus i s largely d ue t o gas;; there i s an absence of those typical splashing sounds which a re obtained o n abdominal palpation i n cases o f mechanical obstruction. There seems little doubt that i n paralytic ileus i s a depression o f more than o n e function o f t h e intestinal tract muscular activity, absorption, a nd perhaps t h e most important o f all, g a s exchange, ar e a l l affected. But what i s t h e effect o f intestinal distension o n t h e body a s a whole? What a r e t h e lethal factors i n paralytic ileus? T h e results which m a y b e attributed directly t o disten- sion o f t h e small intestine a r e very imperfectly under- stood. It i s generally believed that toxic products a r e absorbed from t h e contents o f loops o f intes- tine i n sufficient amounts t o cause death. Some recent articles1 2 have cast doubt o n t he truth o f this view, a n d I have just completed a series o f experiments i n which I failed to find an y evidence whatever t o support this theory, except, o f course, i n t h e presence o f strangulation. T h e most noticeable changes, apart from distension, presented a t operation i n thLe o)bstructed loops o f g u t a re the cyanotic tinge, t^he engorge-ment o f t h e blood vessels, an d the thick oedematous intestinal wall. Sevreral writers
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
8/9/2019 brmedj06839-0007
http://slidepdf.com/reader/full/brmedj06839-0007 1/3
* > x , 1 9 3 6
A
l D H E S I O N I S
OF
J O I T S -
AND
g l J
oAL
-929
p e r f e c t l y r e d u c e d by
o p e r a t i o n ,
t h e wound may h e a l w i t h -
o u t
o b v i o u s
i n f e c t i o n ,
a n d
p a s s i v e
movement and
m a n i p u -
l a t i o n
may
b e a v o i d e d i n a
b l a m e l e s s
a f t e r - t r e a t m e n t ,
a n d
y e t , i f w i r e
i s u s e d f o r
i n t e r n a l f i x a t i o n ,
t h e r e i s u s u a l l y
p e r m a n e n t l i m i t a t i o n o f
e x t e n s i o n movement.
The
w i r e
i s
a s s o c i a t e d
w i t h a
l o w - g r a d e
i n f l a m m a t o r y
r e a c t i o n , a n d
t h e
c o n t i n u e d i r r i t a t i v e
s e r o f i b r i n o u s e x u d a t i o n g i v e s r i s e
t o p e r i a r t i c u l a r
a d h e s i o n
f o r m a t i o n
w h i c h
i s
p a r t i c u l a r l y
r e s i s t a n t .
I n
t h e s e
f r a c t u r e s i t
i s q u i t e
u n n e c e s s a r y
t o
u s e
a n y t h i n g s t r o n g e r
t h a n c a t g u t ,
which
a b s o r b s
s o
r a p i d ly t h a t i t d o e s
n o t g i v e r i s e t o
a d h e s i o n
f o r m a t i o n .
S i m i l a r l y i n
t h e
r e p l a c e m e n t o f
e p i c o n d y l a r
f r a g m e n t s t o
t h e
h u m e r u s , o f
m a l l e o l a r f r a g m e n t s t o
t h e t i b i a ,
and
i n
t h e r e p a i r
o f comminuted
f r a c t u r e s o f t h e
l o w e r e n d
o f
t h e
humerus
and u p p e r e n d o f t h e
t i b i a , p l a t e s ,
s c r e w s ,
and
w i r e s h o u l d
a l w a y s b e a v o i d e d .
The r u s t l e s s
and
s t a i l n l e s s
m e t a l s r e c e n t l y i n t r o d u c e d
p r o d u c e
l e s s
r e a c t i o n
t h a n
o t h e r m e t a ls .
N e v e r t h e l e s s ,
e v e n t h e s e
m e t a l s s h o u ld
b e u s e d w i t h
c a u t i o n , b e c a u s e some
r e a c t i o n d o e s
o c c u r
a f t e r tw o o r t h r e e
m o n t h s . I n f r a c t ur e s o f
t h e
n e c k
o f
t h e
f e m u r
t h e e f f e c t
o f a
s t a i n l e s s s t e e l n a i l
i s m i n i m i z e d
by i t s
d i s t a n c e
f r o m p e r i a r t i c u l a r t i s s u e s .
E v e n s o , i t
a p p e a r s
a d v i s a b l e t o
remove t h e n a i l i n
a l l c a s e s a s
s o o n
a s t h e
f r a c t u r e i s
f i r m l y u n i t e d .
C o n c l u s i o n
I w o u l d
r e p e a t , t h e n ,
t h a t f r a c t u r e s
s h o u l d
b e
p e r f e c t l y
i m m o b i l i z e d
by
c o m p l e t e
f i x at i o n o f
a d j a c e n t
j o i n t s ,
s o
t h a t
a c t i v e movement
o f
d i s t a n t
j o i n t s may
b e
p r a c t i s e d
p a i n l e s s l y .
P a t i e n t s
must
b e
d e f i n i t e l y
i n s t r u c t e d i n
j o i n t
m o b i l i z a t i o n ;
b r i e f l y , a s
f o l l o w s :
C o l l e s s
f r a c t u r e :
F i x
w r i s t ; a c t i v e l y
move
f i n g e r s ,
e l b o w ,
and
s h o u l d e r .
F r a c t u r e d s h a f t s o f
t h e
r a d i u s a n d
u l n a :
F i x e l b o w a n d
w r i s t
a c t i v e l y
move
f i n g e r s
and
s h o u l d e r .
F r a c t u r e s o f t h e
e l b o w :
F i x
e l b o w
a c t i v e l y
move
f i n g e r s ,
w r i s t ,
and
s h o u l d e r .
F r a c t u r e d
s h a f t s
o f
t h e
humerus
a n d
s h o u l d e r :
F i x
s h o u l d e r
and e l b o w
a c t i v e l y
move
w r i s t and
f i n g e r s .
P o t t s f r a c t u r e :
F i x
a n k l e
a c t i v e l y
move
t o e s , k n e e ,
and
h i p .
F r a c t u r e d
s h a f t s
o f
t h e
t i b i a
and
f i b u l a :
F i x a n k l e a n d
k n e e
a c t i v e l y
move
t o e s and
h i p .
F r a c t u r e d
s h a f t
o f
f e m u r : F i x
h i p
and
k n e e
a c t i v e l y
move
a n k l e and
t o e s .
F r a c t u r e d
n e c k o f f e m u r
( w i t h n a i l ) :
A c t i v e l y
move
h i p ,
k n e e , a n k l e ,
and t o e s .
S u m m a r y
1 . J o i n t
s t i f f n e s s
a f t e r
i n j u r y
i s d u e
t o
t h e
a d h e s i o n
o f
c a p s u l a r
p l i c a t i o n s ,
and
t h i s
may
r e s u l t f r o m
t h e
o r g a n -
i z a t i o n
o f
a n y
e x u d a t e
i n
t h e
p e r i a r t i c u l a r t i s s u e s .
2 .
The
a d h e s i o n s
o f
i m m o b i l i z a t i o n , u n c o m p l i c a t e d
b y
o t h e r
f a c t o r s ,
a r e
t e m p o r a r y ,
and r e c o v e r
b y
t h e
p a t i e n t s
own e x e r c i s e .
3 . The
f a c t o r s w h i c h
c o n v e r t
t h e r e c o v e r a b le
s t i f f n e s s
o f
i n j u r e d
i m m o b i l i z e d
j o i n t s
i n t o
i r r e c o v e r a b l e
s t i f f n e s s a r e
t h o s e
r e s p o n s i b l e
f o r
a
c o n t i n u e d
o r
r e p e a t e d
s e r o f i b r i n o u s
e x u d a t i o n :
a )
d i s u s e
w i t h c o n t i n u e d
venous
s t a s i s ;
( b )
r e c u r r e n t
o e d e m a ;
c )
r e p e a t e d
trauma o f
p a s s i v e
s t r e t c h i n g ; ( d )
c o n t i n u e d
i n f e c t i o n
n e a r a
j o i n t
and
i r r i t a -
t i o n
o f
f o r e i g n
b o d i e s
near a
j o i n t .
4 .
F r a c t u r e s s h o u l d
S ~ e
p e r f e c t l y
i m m o b i l i z e d b y
com-
p l e t e
f i x a t i o n
o f
a d j a c e n t j o i n t s ,
s o t h a t
a c t i v e
movements
o f d i s t a n t
j o i n t s
may
b e
p r a c t i s e d p a i n l e s s l y .
R E F E R E N C E S
1
B r i t i s h
M e d i c a l
J o u r n z a l , 1 9 3 2 , i
5 4 2 .
2
I b i d . ,
1 9 3 2 ,
i
1 0 7 3 .
S u p p l e m e n t , B r i t s h
M e d i c a l
J o u r n a l 7 , 1 9 3 5 ,
i
5 3 .
B r i t i s h
M e d i c a . l
J o r n a l .
1 9 3 5 ,
a ,
6 1 6 .
I b i d ,
1 9 2 3 ,
i 1 3 5 ;
1 9 3 3 ,
i ,
3 9 1 .
I b i d . ,
1 9 3 3 , i , 2 4 7
; 1 9 3 3 ,
i ,
3 4 o .
7 L a n . c e t ,
1 9 3 2 ,
i i , 1 2 1 7 .
P r o c .
R o v . S o c ;
M e d . ,
1 9 3 0 , x x i i i , S e c t .
O r t h o p . , 2 3 .
B r i t i s h
- M c d c a l J o u r n z a l , 1 9 3 1 , i i
1 0 1 9 .
TREATMENT
OF
PARALYTIC
ILEUS
BY
R . L .
HOLT, F . R . C . S .
HONORARY
A S S I S T A N T
SURGEON CHRISTIE
IIOSPITAL; C H I E F
A S S I S T A N T ,
S U R G I C A L
UNIT,
M I A N C H E S T E R ROYAL
I N F I R I M A R Y
The o b j e c t o f t h i s
p a p e r i s
t o o u t l i n e a t r e a t m e n t
o f
p a r a l y t i c
i l e u s
w h i c h I h a v e
u s e d a s
a
r o u t i n e d u r i n g
t h e
p a s t
two
y e a r s
w i t h
c o n s i s t e n t l y
g o o d
r e s u l t s .
I n
t h e p a s t
a
v a r i e t y
o f t h e r a p e u t i c
m e a s u r e s h a v e
b e e n
recommended i n
t h e t r e a t m e n t
o f t h i s
c o n d i t i o n and
many o f them h a v e
e n j o y e d
a c e r t a i n m e a s u r e o f
s u c c e s s .
But
p a r a l y t i c i l e u s s t i l l
r e m a i n s o n e
o f t h e most
h a r a s s i n g
p o s t - o p e r a t i v e
c o m p l i c a t i o n s
w h i c h t h e
s u r g e o n
i s
c a l l e d
upon t o
t r e a t .
The c o n d i t i o n
b e g i n s a s a n
i n h i b i t i o n
o f
i n t e s t i n a l
t o n e a n d m o t i l i t y
a s
a
r e s u l t o f
i n j u r y o f t h e
n e u r o - m u s c u l a r
mechanism
o r o f i n h i b i t o r y
i m p u l s e s f r o m
t h e
s p i n a l c o r d and c o e l i a c
p l e x u s .
I n t h e e a r l y s t a g e s
t h e
i n t e s t i n a l
m u s c l e i s
c a p a b l e
o f
c o n t r a c t i n g
i f
s u i t a b l y
s t i m u l a t e d .
I n t h e l a t e r
s t a g e s , p e r h a p s
a s a r e s u l t o f
o v e r s t r e t c h i n g
and
c i r c u l a t o r y
d i s t u r b a n c e s , t h e i n t e s t i n a l
m u s c l e
l o s e s
i t s c o n t r a c t i l e
p o w e r and d o e s n o t
r e a d i l y
r e g a i n
i t .
The common
method
o f t r e a t m e n t
i s
t o u s e some
d r u g
o r m e a s u r e w h i c h
u n d e r n o r m a l
c o n d i t i o n s
w i l l
augment
i n t e s t i n a l p e r i s t a l s i s .
Many c a s e s o f
i n t e s t i n a l
p a r e s i s
may
b e
r e s o l v e d
by t h e
t i m e l y
u s e o f s u c h
d r u g s
a s p i t u i t r i n ,
e s e r i n e , a c e t y l c h o l i n e ,
e t c . ,
b u t
t h i s
i s n o t
s u r p r i s i n g
when t h e many g r a d e s
i n
w h i c h t h i s c o n d i t i o n
o c c u r s a r e c o n s i d e r e d .
The f a c t r e m a i n s
t h a t many
o t h e r
c a s e s
d o
n o t r e s p o n d
t o
s t i m u l a n t
m e a s u r e s ,
and
f r e q u e n t l y
t h e c o n c l u s i o n
c a n n o t b e e s c a p e d
t h a t
t h e
c o n t i n u e d
u s e
o f s u c h m e a s u r e s h a s
an i l l
e f f e c t o n t h e
p r o g r e s s o f t h e
p a t i e n t . The
t o o l i t e r a l a d o p t i o n
o f
t h e
o l d
d i c t u m
G e t
t h e b o w e l s
o p e n
a n d t h e
p a t i e n t w i l l
l i v e ,
w h i c h h a s
l o n g
f o r m e d t h e b a s i s o f t h e t r e a t m e n t
o f
p a r a l y t i c i l e u s ,
i s l i k e l y
t o k i l l more
p a t i e n t s
t h a n
i t
w i l l
s a v e .
P h y s i o p a t h o l o g y
o f
P a r a l y t i c l l e u s -
Whatever
t h e
c a u s e
o f
t h e
c o n d i t i o n ,
t h e
e s s e n t i a l
c l i n i c a l
f e a t u r e s a r e
a d i s t e n s i o n
o f t h e i n t e s t i n a l t r a c t
- u s u a l l y
most
marked
i n t h e
s m a l l
i n t e s t i n e - a n d a
c o m p l e t e
o r
a l m o s t
c o m p l e t e
a b s e n c e
o f i n t e s t i n a l
move-
m e n t s . V o m i t i n g
i s
n o t
s o
marked
a
symptom
i n
p a r a l y t i c i l e u s
a s i n
m e c h a n i c a l
o b s t r u c t i o n ,
and
u n l e s s
t h e
p a t i e n t
h a s
b e e n
g i v e n
l a r g e
amounts
o f f l u i d
by
mouth
t h e
i n t e s t i n a l
d i s t e n s i o n
i n
p a r a l y t i c
i l e u s
i s
l a r g e l y
d u e
t o g a s ; ;
t h e r e
i s
an
a b s e n c e
o f
t h o s e t y p i c a l s p l a s h i n g
s o u n d s
w h i c h
a r e o b t a i n e d
on a b d o m i n a l
p a l p a t i o n
i n
c a s e s o f
m e c h a n i c a l
o b s t r u c t i o n .
T h e r e seems
l i t t l e d o u b t
t h a t i n
p a r a l y t i c
i l e u s
t h e r e
i s
a
d e p r e s s i o n
o f more t h a n
o n e
f u n c t i o n
o f
t h e i n t e s t i n a l
t r a c t
m u s c u l a r
a c t i v i t y ,
a b s o r p t i o n ,
a n d
p e r h a p s
t h e
most
i m p o r t a n t
o f
a l l , g a s
e x c h a n g e ,
a r e
a l l a f f e c t e d .
But what
i s
t h e
e f f e c t o f
i n t e s t i n a l
d i s t e n s i o n
on
t h e
b o d y
a s
a
w h o l e ? What
a r e
t h e
l e t h a l
f a c t o r s
i n
p a r a l y t i c
i l e u s ?
The
r e s u l t s
w h i c h
may
b e
a t t r i b u t e d
d i r e c t l y
t o d i s t e n -
s i o n
o f
t h e
s m a l l i n t e s t i n e
a r e
v e r y i m p e r f e c t l y
u n d e r -
s t o o d .
I t i s
g e n e r a l l y
b e l i e v e d
t h a t t o x i c
p r o d u c t s
a r e
a b s o r b e d
f r o m t h e
c o n t e n t s o f d i s t e n d e d
l o o p s
o f i n t e s -
t i n e
i n
s u f f i c i e n t
amounts t o
cause d e a t h .
Some r e c e n t
a r t i c l e s 1
2
h a v e
c a s t
d o u b t on
t h e t r u t h
o f
t h i s
v i e w ,
a n d
I
h a v e
j u s t c o m p l e t e d
a
s e r i e s
o f
e x p e r i m e n t s
i n
w h i c h
I f a i l e d
t o f i n d
any
e v i d e n c e
w h a t e v e r
t o
s u p p o r t
t h i s
t h e o r y ,
e x c e p t ,
o f
c o u r s e ,
i n
t h e
p r e s e n c e
o f
s t r a n g u l a t i o n .
The m o s t
n o t i c e a b l e c h a n g e s , a p a r t f r o m
d i s t e n s i o n ,
p r e s e n t e d
a t
o p e r a t i o n
i n
t h L e
o ) b s t r u c t e d
l o o p s o f g u t
a r e
t h e c y a n o t i c
t i n g e ,
t ^ h e e n g o r g e - m e n t
o f
t h e
b l o o d
v e s s e l s ,
and t h e t h i c k o e d e m a t o u s i n t e s t i n a l
w a l l .
S e v r e r a l
w r i t e r s
8/9/2019 brmedj06839-0007
http://slidepdf.com/reader/full/brmedj06839-0007 2/3
9 3 1 1
M A r
~~ ~U
T R E A 1 ~ ~ M N T .
O F
A R A 1 t t Y 1 T C
T.EC
h a v e drawn
a t t e n t i o n t o
t h e
l a r g e
a c c u m u l a t i o n
o f
f l u i d
i n t h e
s p l a n c h n i c a r e a
i n
p a t i e n t s
d y i n g o f
p a r a l y t i c
i l e u s .
I h a v e f o u n d e x p e r i m e n t a l ly t h a t t h e
m o s t
s t r i k i n g
c h a n g e
w h i c h t a k e s
p l a c e i n l o o p s
o f
i n t e s t i n e i n
w h i c h
d i s t e n s i o n
d e v e l o p s
g r a d u a l l y i s
t h e
l a r g e amount
o f
t i s s u e f l u i d
w h i c h f i l l s t h e d i s t e n de d
t i s s u e s p a c e s o f
t h e
v a r i o u s
l a y e r s
f o r m i n g
t h e
i n t e s t i n a l w a l l . I
b e l i e v e
t h a t
t h e m o s t s e r i o u s
f a c t o r
i n c a s e s o f
i l e u s i s t h e
c i r c u l a t o r y
f a i l u r e
w h i c h
r e s u l t s
f r o m t h e
s t a g n a t i o n
o f
b l o o d and t i s s u e
f l u i d
i n t h e d i s t e n de d l o o p s o f
g u t
a n d
i n
t h e
p e r i t o n e a l
c a v i t y .
The
c i r c u l a t i o n
i s
f u r t h e r e m b a r r a s s e d
by
t h e amount
o f f l u i d l o s t
by
v o m i t i n g .
The
l o g i c a l
t r e a t m e n t
o f
p a r a l y t i c
i l e u s ,
t h e r e -
f o r e ,
w o u l d
a p p e a r
t o c o n s i s t
i n :
1 .
R e l i e vi n g t h e d i s t e n s i o n
o f
t h e
s m a l l
i n t e s t i n e .
2 .
M a i n t a i n i n g
t h e c i r c u l a t i o n .
E f f e c t s
o f
P e r i t o n i t i s
The
c a s e s o f
p a r a l y t i c i l e u s commonly s e e n
by
t h e
s u r g e o n c a n b e
d i v i d e d
i n t o two
g r o u p s ,
a c c o r d i n g
t o
w h e t h e r a p e r i t o n i t i s
i s
p r e s e n t
o r n o t .
O b v i o u s l y
i n
t h e
g r o u p a s s o c i a t e d w i t h p e r i t o n i t i s t h e
r e s u l t s o f
t r e a t -
ment
c a n n o t
b e e x p e c t e d t o b e a s g o o d
a s t h o s e
o f t h e
o t h e r
g r o u p , s i n c e t h e p e r i t o n e a l i n f e c t i o n
a d d s a
c o m -
p l i c a t i n g f a c t o r w h i c h may
b e s u f f i c i e n t
i n i t s e l f t o
c a u s e
d e a t h .
O f t e n
t h e
p e r i t o n e a l
i n f e c t i o n
i s
n o t
s u c h
a s
t o
c a u s e
d e a t h by i t s e l f ,
a n d i n t h e s e c a s e s
i t
i s
t h e
c o m b i n e d
e f f e c t s o f p e r i t o n i t i s
and
p a r a l y t i c i l e u s
w h i c h
p r o v e f a t a l - o f t e n t h e l a t t e r i s
t h e
m o r e i m p o r t a n t
f a c t o r .
I n c a s e s
o f
p e r i t o n i t i s
I
m e r e l y c l a i m
t ha t t he
e f f e c t s o f
any
a s s o c i a t e d
p a r a l y t i c i l e u s
c a n b e c o n t r o l l e d
by
t h e
m e t h o d s t o
b e
d e s c r i b e d .
P r o p h y l a x i s a n d D r u g T h e r a p y
P a r a l y t i c
i l e u s i s
f r e q u e n t l y t h e
r e s u l t o f
a f a u l t y
s u r g i c a l
t e c h n i q u e . Many c a s e s c a n
b e
t r a c e d
t o
e x c e s -
s i v e
p a c k i n g o f f a n d
m a n i p u l a t i o n
o f
t h e s ma ll i n t e s t i n e ,
w h i c h s h o u l d
b e
a v o i d e d ,
e s p e c i a l l y
i n
t h e p r e s e n c e o f
a p e r i t o n i t i s .
The
i n c i d e n c e o f
i l e u s c a n
b e l e s s e n e d
by
a d o p t i n g
t h e
f o ll ow i n g p o s t - op e r a t i v e
m e a s u r e s
i n
c a s e s
i n
w h i c h
t h e r e
i s
b e li e v e d t o
b e
any
d a n g e r
o f
t h i s
c o n d i t i o n
d e v e l o p i n g .
The i m p o r t a n c e
i n
s u c h c a s e s
o f
k e e p i n g t h e i n t e s t i n a l
t r a c t
a s
c o m p l e t e l y
r e s t e d
a s
p o s s i b l e c a n n o t
b e t o o
s t r o n g l y
e m p h a s i z e d . P u r g a t i v e s , e n e m a t a ,
e t c . , a r e d e f i n i t e l y c o n t r a -
i n d i c a t e d .
No f l u i d
w h a t e v e r
i s
a l l o w e d
by t h e
m o u t h , w h i c h i s
k e p t
f r e s h
by
f r e q u e n t
m o u t h - w a s h e s ,
a n d
b y c h e w i n g - g u m ,
o r ,
b e t t e r
s t i l l ,
b y
raw
p i n e a p p l e .
N o r m a l
s a l i n e
i s
g i v e n
i n
s u f f i c i e n t
amount
( u s u a l l y 6 t o 8
p i n t s )
b y
any
o f
t h e a v a i l a b l e
r o u t e s ,
b u t
p r e f e r a b l y
i n t r a -
v e n o u s l y . M o r p h i n e
i s
g i v e n
i n
d o s e s o f
1 / 6
g r a i n e v e r y
s i x
h o u r s .
I n t h e
a b s e n c e
o f
t h e
d e v e l o p m e n t
o f
i n t e s t i n a l
d i s t e n s i o n
w a t e r
may
b e
g i v e n b y
mouth
on
t h e t h i r d
d ay , b e g i n ni n g
w i t h s m a l l
q u a n t i t i e s , s a y ,
o ne o un ce
h o u r l y .
The
u s u a l
outcome
o f t h i s
t r e a t m e n t
i s
a
v e r y s m o o t h
p o s t - o p e r a t i v e p e r i o d ,
and a l m o s t
w i t h o u t
e x c e p t i o n
t h e
b o w e l s
a r e
moved
n a t u r a l l y
o n
t h e f o u r t h
d a y .
I d o n o t
i n t e n d
t o d i s c u s s
t h e us e o f
d r u g s
a t
any
l e n g t h .
t
h a s
a l r e a d y
b e e n
i n d i c a t e d
t h a t
t h e
t i m e l y
u s e o f
s u c h
d r u g s
a s
p i t u i t r i n , e s e r i n e ,
a c e t y l c h o l i n e ,
e t c . , ma y p r o d u c e
g o o d
r e s u l t s .
T h e r a p e u t i c
measures
d e s i g n e d
t o
s t i m u l a t e i n t e s t i n a l
p e r i s t a l s i s
may
b e
t r i e d
o n c e ,
b u t
i f
t h e y
f a i l
t h e y
s h o u l d n o t b e
r e p e a t e d .
Some
t h r e e
y e a r s a g o
I had
o c c a s i o n
t o
o p e r a t e o n
a
c a s e
o f
p a r a l y t i c
i l e u s d u e
t o
o b s t r u c t i o n
o f
t h e t e r m i n a l
i l e u m
by
a
b a n d .
A
s p i n a l
a n a e s t h e t i c was
u s e d ,
a n d
a t no
t i m e
d u r i n g t h e o p e r a t i o n
was t h e r e
a n y
e v i d e n c e o f
p e r i s t a i l s i s ,
n o r
c o u l d
any
m u s c u l a r
c o n t r a c t i o n
b e e v o k e d
by
t h e
u s u a l
m e t h o d s
o f s t i m u l a t i o n .
T h e s e
f i n d i n g s
h a v e
s i n c e
b e e n
c o n f i r m e d
on s e v e r a l
o c c a s i o n s .
I t s e e m s
h a r d l y
c r e d i b l e t h a t
any
r e s u l t
c a n b e e x p e c t e d
f r o m
t h e u s e
o f
d r u g s i n
s u c h
c a s e s .
R e l i e v i n g D i s t e n s i o n b y D e c o m p r e s s i o n
A f e w w o r d s
m i g h t b e i n s e r t e d h e r e a b o u t
t h e
v e x e d
q u e s t i o n o f
e n t e r o s t o m y . D r a i n a g e i s
o f t e n l i mi t e d by
k i n k i n g
o f t h e g u t , a n d
a
v i r u l e n t p e r i t o n i t i s
i s
n o t
an
u n u s u a l
s e q u e l t o
t h i s
o p e r a t i o n .
T h e r e
i s n o d o u b t
t h a t
e n t e r o s t o m y
h a s
s a v e d
many l i v e s , b u t t o o o f t e n
i t
i s
u n s a t i s f a c t o r y .
I n
p a r a l y t i c
i l e u s
a n e n t e r o s t o m y
d r a i n s
v e r y
p o o r l y , a n d I b e l i e v e
t h a t
i t s
u s e
h a s b e e n e n t i r e l y
s u p e r s e d e d by t h e
m e a s u r e
d e s c r i b e d by
A m e r i c a n
w r i t e r s
4
5 u n d e r
t h e
t e r m
i n t e s t i n a l d e c o m p r e s s i o n .
T h i s
method i s
more
e f f e c t i v e t h a n a n
e n t e r o s t o m y
a n d
h a s
n o n e o f
i t s
r i s k s .
The p r i n c i p l e o f t h e
method
i s
t h e a p p l i c a t i o n
o f
c o n t i n u o u s m i l d s u c t i o n
t o a n
i n d w e l l i n g t u b e
i n
t h e
s t o m a c h
o r
d u o d e n u m . I t
h a s
b e e n
shown e x p e r i m e n t a l l y
t h a t
t h e
i n t e s t i n a l
t r a c t
c a n
b e
d r a i n e d a s f a r
a s
t h e
i l e o - c a e c a l
v a l v e
by s u c h
methods; I h a v e
b e e n a b l e
t o
v e r i f y
t h i s a t
o p e r a t i o n
i n
o n e c a s e .
CONTINUOUS
SUCTION
APPARATUS
The
a p p a r a t u s
u s e d i s
shown
i n t h e a c c o m p a n y i n g d i a g r a m r
i t
i s
somewhat
s i m p l e r
t h a n
t h a t
d e s c r i b e d
by W a n g e n s t e e n
and
P a i n e . 6
I t
c o n s i s t s o f a
d u o d e n a l
t u b e
w h i c h
i s
p a s s e d
by
mouth o r
t h r o u g h
t h e n a r e s . T h i s i s
a t t a c h e d
t o a
T - p i e c e ,
o n e l i m b
o f w h i c h
i s a t t a c h e d
t o a r e s e r vo i r ( A) c o n -
t a i n i ng t a p - w a t e r
a n d
p l a c e d a t a h e i g h t o f a b o u t
2
f e e t
a b o v e
t h e
p a t i e n t
t o t h e o t h e r l i m b i s
a t t a c h e d
a p i e c e o f
r u b b e r
t u b i n g ,
w h i c h
d r a i n s
i n t o
a
b o t t l e
( B )
o n
t h e
f l o o r
by
t h e b e d si de .
I t i s
i m p o r t a n t
t ha t t h e
e n d
o f t h i s t u b e s h o u l d b e
b e l o w
t h e
l e v e l o f
t h e f l u i d
i n
t h e
b o t t l e
( B ) . The
d i f f e r e n c e
i n
h e i g h t
b e t w e e n
t h e
o p e n
e n d o f
t h e
d u o d e n a l
t u b e
and
t h e
l e v e l
o f
t h e
f l u i d
i n
t h e
b o t t l e ( B )
s u p p l i e s by
s i p h o n a c t i o n
t h e c o n t i n u o u s m i l d
s u c t i o n
n e c e s s a r y .
I t h a s b e e n
f o u n d
i n
p r a c t i c e
t h a t
t h e
b e s t
r e s u l t s
a r e o b t a i n e d
when
t h e
d i f f e r -
e n c e
i n
t h e s e two
l e v e l s
i s a b o u t 2 f e e t
t o
2
f e e t 6 i n c h e s .
A i r
i s
r e m o v e d
i n i t i a l l y
f r o m
t h e
a p p a r a t u s
b y f i l l i n g
i t
w i t h
w a t e r
f r o m t h e r e s e r v o i r
( A ) .
The
c l i p ( C )
i s
t h e n
c l o s e d , c l i p ( D )
i s
l e f t
o p e n ,
a n d
t h e s t o m a c h c o n t e n t s
b e g i n
t o
s i p h o n
o f f : The f a c t
t h a t
s i p h o n a g e
i s
a c t u a l l y t a k i n g
p l a c e
s h o u l d
b e v e r i f i e d
f r e q u e n t l y ,
s i n c e
t h e
d u o d e n a l t u b e
f r o m t i m e
t o
t i m e
g e t s
b l o c k e d
w i t h -
mucus
and d e b r i s . I t
i s
u s u a l l y u n n e c e s s a r y
t o
remove
i t ,
f o r i t
can
g e n e r a l l y
b e
w a s h e d
c l e a r
b y
w a t e r ,
t o
w h i c h s o d i u m
b i c a r b o n a t e ,
ma y
b e
a d d e d ,
from
r e s e r v o i r
( A ) .
I n t h i s
way
t h e
i n t e s t i n a l
c o n - -
I
-1
I
8/9/2019 brmedj06839-0007
http://slidepdf.com/reader/full/brmedj06839-0007 3/3
M A Y
9 ,
t S
rOF A 1
O F ,
OPARALYTt,
S I L E V S t
2 T
9 9 S
19
UrCAL
OU
i t Z I A _
t e n t s
a r e
r e m o v e d ,
and
i t w i l l b e
f o u n d t ha t t h e
a b d o m i n a l
d i s t e n s i o n
g r a d u a l l y d e c r e a s e s .
As
a r u l e
t h e p a t i e n t
w i l l
b e
f o u n d
t o
t o l e r a t e
t h e i n d w e l l i n g
d u o d e n a l t ub e v e r y
w e l l ;
n e v e r t h e l e s s I
p r e s c r i b e
a s
a
r o u t i n e
1 / 6 g r a i n m o r p h i n e
s i x - h o u r l y .
The p a t i e n t
c b t a i n s
prompt
r e l i e f
f r o m
v o m i t i n g
and
f r o m
t h e
d i s c o m f o r t
due
t o a b d o m i n a l
d i s t e n s i o n .
I t
i s
p o s s i b l e , and
i n d e e d p r e f e r a b l e ,
t o a l l o w
f l u i d s by mouth
a s s o o n
a s
t h e a p p a r a t u s i s
f u n c t i o n i n g .
I t
g i v e s
t h e
p a t i e n t a
g o o d d e a l
o f c o m f o r t and
h e l p s t o k e e p
t h e
mouth
f r e s h ,
and
a t
t h e same t i m e
i t
d o e s
n o h a r m ,
s i n c e
t h e f l u i d i s p r o m p t l y
removed
f r o m t h e s t o m a c l h
b y t h e i n d w e l l i n g
t u b e . T h i s
i n t e s t i n a l
d e c o m p r e s -
s i o n i s k e p t up
u n t i l
t h e
a b d o m i n a l
d i s t e n s i o n h a s
c o m p l e t e l y
d i s a p p e a r e d and t h e b o w e l s
h a v e b e e n o p e n e d
n - a t u r a l l y , an e v e n t w h i c h
u s u a l l y t a k e s
p l a c e
a b o u t
t h e
f o u r t h
day a f t e r
t h e
t r e a t m e n t
i s
b e g u n .
M a i n t a i n i n g
t h e
C i r c u l a t i o n .
The c i r c u l a t i o n
i s b e s t
m a i n t a i n e d
by g i v i n g
n o r m a l
s a l i n e
i n t r a v e n o u s l y
by t h e c o n t i n u o u s
d r i p m e t h o d .
About
s i x
t o e i g h t
p i n t s a
day
a r e u s u a l l y
s u f f i c i e n t
f o r
a n
a d u l t , b u t
t h e amount c a n b e r e g u l a t e d
by t h e
q u a n t i t y
o f u r i n e
p a s s e d , w h i c h s ho u l d n o t
b e
l e s s t h a i i
o n e and
a
h a l f
p i n t s
i n
t w e n t y - f o u r
h o u r s . The
s a l i n e
s h o u l d
b e made
up
f r o m
t r e b l y
d i s t i l l e d
w a t e r ,
i n
w h i c h
c a s e i t
w i l l b e
f o u n d
t h a t t h e
d r i p c a n b e k e p t
up
w i t h o u t any
r e a c t i o n
o r
l o c a l
p hl e bi t i s f o r
a
week o r
m o r e ,
i f n e c e s s a r y .
Once t h e b o w e l s
h a v e
moved
n a t u r a l l y and
t h e d i s t e n -
s i o n
h a s d i s a p p e a r e d
t h e d u o d e n a l
t u b e c a n b e r e m o v e ( d
and
t h e
p a t i e n t may
b e
a l l o w e d
t o t a k e s m a ll
d r i n k s
b y
m o u t h , b e g i n n i n g
w i t h o n e
o u n c e o f w a t e r h o u r l y
f o r
t h e f i r s t
t w e n t y - f o u r
h o u r s . T h i s
i s g r a d u a l l y
i n c r e a s e d
a n d a t
t h e
same t i m e
t h e
amount
o f
s a l i n e
g i v e n i s
d e c r e a s e d . An y
r e t u r n
c f
d i s t e n s i o n o r
v o m i t i n g
i s
u n u s u a l ,
a n d i s
t r e a t e d
b y
r e i n s e r t i n g
t h e d u o d e n a l
t u b e .
R e s u l t s o f
T r e a t m e n t
The
i m m e d i a t e
i m p r o v e m e n t
i n
t h e
p a t i e n t s
c o n d i t i o n
f o l l o w i n g
t h e
i n s t i t u t i o n
o f
t h i s t r e a t m e n t
i s
n o t
s p e c -
t a c u l a r . V o m i t i n g
i s
a t
once
r e l i e v e d
a n d
t h e
d i s c o m f o r t
d u e t o
t h e
a b d o m i n a l d i s t e n s i o n
i s
l e s s e n e d
a s
t h e
i n t e s t i n a l
c o n t e n t s
a r e
s i p h o n e d
o f f .
The
d i s t e n s i o n
g r a d u a l l y
d i m i n i s h e s ,
b u t
t h e
p u l s e
r a t e
d o e s n o t
f a l l
a p p r e c i a b l y
d u r i n g
t h e f i r s t
two
o r
t h r e e
d a y s .
I n t h e
m a j o r i t y
o f c a s e s
t h e c o n d i t i o n
i s
c l e a r i n g
up
s a t i s -
f a c t o r i l y b y
t h e
f o u r t h
d a y ,
b u t
i n
o t h e r
c a s e s
t h e
p e r i o d
i s
p r o l o n g e d ,
and
tw o
c a s e s
i n
my
e x p e r i e n c e
h a v e
g o n e
e i g h t
a n d
t w e l v e
d a y s
r e s p e c t i v e l y
b e f o r e
i m p r o v i n g .
I t i s
a p p a r e n t
t h a t
t h e i n t e s t i n a l
m u s c l e
d o e s
n o t r e c o v e r
i t s
f u n c t i o n
r a p i d l y ,
h e n c e
t h e
i m p o r t a n c e
o f
r e s t i n g
t h e
i n t e s t i n a l
t r a c t
a s
c o m p l e t e l y
a s
p o s s i b l e
d u r i n g
t h e
r e c o v e r y
p h a s e .
For t h i s r e a s o n
I b e l i e v e
t h a t
p u r g a t i v e s ,
e n i ? m a t a ,
s t i m u l a n t
d r u g s , e t c . ,
a r e
c o n t r a i n d i c a t e d
i n
t h e
t r e a t m e n t c f
t h e
e s t a b l i s h e d
c a s e
o f
p a r a l y t i c
i l e u s .
The
r e s u l t s o f
t h i s
t r e a t m e n t
i n
a
s h o r t
s e r i e s
o f c a s e s
h a v e
b e e n
most
e n c o u r a g i n g .
I n
t e n c a s e s o f
p a r a l y t i c
i l e u s
n o t a s s o c i a t e d
w i t h
p e r i t o n i t i s
t h e r e h a s b e e n
o n e
d e a t h ;
t h i s
o c c u r r e d a f t e r
t h e
p a r a l y t i c
i I e u s
had
c l e a r e d
u p ,
a n d
w a s .
d u e
t o
a
p u l m o n a r y e m b o l u s .
The
o p p o r t u n i t i e s
o f
t r e a t i n g
c a s e s a s s o c i a t e d
w i t h
p e r i t o n i t i s
h a v e
n o t b e e n s o numerous:
f i v e
c a s e s
h a v e
b e e n
t r e a t e d
w i t h
one
d e a t h - t h i s
p a t i e n i t ,
a
g i r l
w i t h
g e n e r a l
p e r i t o n i t i s
d u e t o
a c u t e
a p p e n d i c i t i s ,
d i e d
w i t h
a l l
t h e
s i g n s
a n d
s y m p t o m s
o f
an
a c u t e
p e r i t o n i t i s .
A b d o m i n a l
d i s t e n s i o n ,
w h i c h h a d b e e n
marked a t
o p e r a -
t i o n ,
had a l m o s t
d f i s a p p e a r e d
u n d e r
t r e a t m e n t .
Many o t h e r c a s e s ,
n o t i n c l u d e d i n
t h e a b o v e
s e r i e s ,
h a v e b e e n
t r e a t e d by
my
c o l l e a g u e s a n d
by t h e
s e n i o r
r e s i d e n t s
a t
t h e
M a n l c h e s t e r
R o y a l I n f i r m a r y
w i t h
e q u a l l y
e n c o u r a , g i n g
r e s u l t s . ;
C o n c h u s i o n
A
r o u t i n e i s d e s c r i b e d f o r t h e t r e a t m e n t o f p a r a l y t i c
i l e u s
which i s
b a s e d
on
t h e p h y s i o p a t h o l o g y o f
t h i s
c o n d i t i o n .
The
r e s u l t s h a v e
b e e n
a
g r e a t improvement on
t h o s e
o b t a i n e d by any
o t h e r
method which
I have s e e n
t r i e d .
R E F E R E N C E S
E l m a n , R . ,
a n d
H a r t m a n n , A . F . :
S t r _ . ,
G y n e c o l .
a n z d
O b s t e t . ,
1 9 3 1 ,
l x i i ,
3 0 7 .
2
E l m a n ,
R . :
I b i d . ,
1 9 3 3 ,
} v i ,
1 7 5 .
W a r d , R . :
J o u r n .
A n m e r .
M e d .
A s s o c . ,
1 9 2 5 ,
l x x - . \ i ,
1 1 1 4 .
4 I c I v e r ,
M I .
A . ,
B e n e d i c t ,
E . B . ,
a r n d C l i i i e ,
J .
X N . ,
j u n . : A r c h .
S n Y r g . ,
1 9 2 6 ,
x i i i ,
5 8 8 .
P a i n e , J . R . , C a r i s o n , H . A . ,
and
W a n g e n s t e e n ,
0 .
H . : b o u r n .
A m t e r . M e d . A s s o c . ,
1 9 3 3 ,
c ,
1 9 1 0 .
6
W a n g e n s t e e n , 0 . H . ,
a n d P a i n e , J .
R . :
I b i d . ,
1 9 3 3 ,
c i ,
1 5 3 2 .
CHRONIC AIENINGOCOCCAL
SEPTICAEMIA
B Y
A . M .
S TE WART- WALLACE,
M . B . ,
M . R . C . P .
M D L I ) I C A L
F I R S T
A S S I S T A N T
A N D
R E G I S T R A R ,
L O N D O N
I I O S P I T A L
S i n c e
Gw yn
i n
1 8 9 9 f i r s t e s t a b l i s h 3 d
m e n i n g o c o c c a e m i a
i n
a
c a s e
o f
m e n i n g i t i s
w i t h
a r t h r i t i s ,
and
W a r f i e l d
and
Walker d e s c r i b e d
a
c a s e o f
m e n i n g o c o c c a l
e n d o c a r d i t i s
w i t h s e p t i c a e m i a
i n
1 9 0 3 ,
i t h a s
b e e n i
g r a d u a l l y r e c o g n i z e d
t h a t , i n
a d d i t i o n
t o t h e
s h o r t
i n i t i a l
i n v a s i o n o f
t h e
b l o o d by
t h a
m e n i n g o c o c c i
w h i c h p r o b a b l y
p r e c e d e s
i n f e c t i o n o f
t h e
m e n i n g e s
i n
m o s t i f
n o t a l l
c a s e s
o f
m e n i n g o c o c c a l
m e n i n g i t i s , m e n i n g o c o c c a l
s e p t i c a e m i a
may a l s o o c c u r
i n a s u b a c u t e
o r c h r o n i c f o r m
l a s t i n g
m i a n y
w e e k s
o r m o n t h s ,
i n w h i c h
t h e m e n i n g e s
may
o r
may
n o t b e
i n v o l v e d , t h e s e p t i c a e m i a
b e i n g t h e
s t r i k i n g
c l i n i c a l f e a t u r e .
T h i s
t y p e
i s
w e l l
r e c o g n i z e d
by
w r i t e r s
a b o u t
t h e
war
p e r i o d ,
more p a r t i c u l a r l y
i n t h e
F r e n c h
l i t e r a t u r e .
S i r
Humphry
R o l l e s t o n , i n h i s Lum-
l e i a n
L e c t u r e s
i n 1 9 1 9 ,
s a i d
t h a t
i n t e r m i t t e n t
m e n i n g o -
c o c c a l
f e v e r d u e t o
s e p t i c a e m i a
m i g h t
( a ) l a s t f o r
w e e k s
o r months
w i t h o u t any m e n i n g e a l symptoms
d e v e l o p i n g ;
( b )
f o l l o w m e n i n g i t i s
( c )
show t r a n s i e n t
m e n i n g i t i c
symptoms;
o r ( d ) m i g h t
t e r m i n a t e
i n
m e n i n g i t i s .
He
s t a t e d
t h a t
a
c o r r e c t d i a g n o s i s
was s e l d o m made i n t h e
a b s e n c e
o f
m e n i n g e a l
s y m p t o m s .
I n
s p i t e
o f
t h e s e
d e s c r i p t i o n s
i t
i s f e l t t h a t
t h e more
c h r o n i c
f o r m s
o f
m e n i n g o c o c c a l
s e p t i c a e m i a
w i t h
t h e i r
c h a r a c t e r i s t i c
c l i n i c a l f e a t u r e s
a r e n o t
s u f f i c i e n t l y
o f t e n
r e c o g n i z e d ,
a n d d o
n o t
a t t h e
p r e s e n t
t i m e
r e c e i v e
g e n e r -
a l l y
t h e a t t e n t i o n t h e y m e r i t , s e e i n g
t h a t
no
f e w e r
t h a n
t h r e e
u n c o n n e c t e d
c a s e s ,
which
a r e d e s c r i b e d h e r e ,
h a v e
o c c u r r e d
i n t h e London
H o s p i t a l
d u r i n g
t h e l a s t
two
y e a r s .
T h e s e f o l l o w tw o
f u r t h e r c a s e s o f a s i m i l a r
n a t u r e
i n t h e
same w a r d s , r e p o r t e d
by
Lawson S t o t e
i n 1 9 2 9 .
C a s e
R e p o r t s
C A S E
I
A
p r i n t e r
a g e d
2 5
was a d m i t t e d t o t h e
London
H o s p i t a l
on
March 3 1 s t ,
1 9 3 4 ,
u n d e r
D r .
H u t c h i s o n ,
w i t h
t h r e e w e e k s
h i s t o r y
o f an
i l l n e s s c h a r a c t e r i z e d
a t
t h e
o n s e t
by
h e a d a c h e ,
and
f o l l o w e d
l a t e r
b y
f e v e r , p a i n
i n t h e
l e g s ,
a n d
t e n d e r ,
r e a
c u t a n e o u s
n o d e s
on
h i s
l i m b s .
H i s t o r y . - T h r e e
w e e k s
p r e v i o u s l y
h e h a d
aw
o k e n i n
t h e
e a r l y
m o r n i n g
w i t h s e v e r e
f r o n t a l
h e a d a c h e ,
w h i c h
p a s s e d
o f f
a f t e r
a f e w
h o u r s .
He
v o m i t e d
o n c e ,
f e l t
w e a k ,
a n d
s t a y e d
a t
h o m e . D u r i n g t h e
next two
d a y s
h e
d e v e l o p e d
s p a s m s
o f
g r i p p i n g
p a i n
i n t h e
r i g h t
h e e l ,
w h i c h
o c c a s i o n a l l y .
r a d i a t e d
up
t h e
l e g
a n d
b a c k
t o
t h e
n a p e
o f t h e n e c k .
He t r i e d t o
work
d u r i n g
t h e
two
s u c c e e d i n g
d a y s ,
b u t
h a d
a c o n s t a n t
f r o n t a l
h e a d a c h e ,
f e l t
l e t h a r g i c ,
and commenced
t o h a v e
p a i n s
i n
h i s
k n e e s
and
a n k l e s .
S i n c e
t h e n
h e
h a d
b e e n c o n f i n e d t o
b e d
v i t h
f e v e r ,
p r o f u s e
s w v e a t s ,
e s p e c i a l l y
a t
n i g h t ,
p a i n s
i n
h i s
- l e g s ,
a n d s e v e r e
h e a d a c h e
d u r i n g
t h e f i r s t
f e w
d a y s
t h e
Related Documents
