MARCH 31, 1951
ACUTE PERFORATION TREATED CONSERVATIVELY
unrecognized air swallowing in the aspiration method of treatment. There are no post-operative chest complications, so common after operation for perforation. It may be that the risk of subphrenic abscess will be reduced, if not entirely eliminated, for it is likely that the patient's increased respiratory excursions while under the influence of the anaesthetic can, by suction, fill the subphrenic spaces with peritoneal exudate. What the ultimate fate of these patients will be it is not possible to say at present. So far only Case 5 has been submitted to operation. All the others left hospital symptom-free; though of course on strict ulcer diet. Case 12 should certainly be subjected to gastrectomy if the gastric ulcer is still present on review. If and when gastrectomy or other operative procedure is required in any of these cases it is to be expected that easier operating conditions will be found than would be the case if a laparotomy had already been performed. It will be noted from the follow-up that 13 of the 15 cases were seen on the average almost 12 months after perforation, and that their condition was at least no worse than if they had been subjected to an immediate operation. The above series of cases is admittedly a small one, but, even so, I would suggest that immediate operation in simple gastro-duodenal perforation is no longer necessary, and that any operative intervention should be reserved for such complications as may arise. Since this paper was written further cases have been similarly treated with equal success. I wish to thank Mr. J. C. Jefferson for the watchful eye he kept on the patients and for his help and criticism of this paper; also Dr. T. Benson, house-surgeon, for his enthusiastic co-operation. REFERENCES Avery Jones, F., Parsons, P. J., and White, Barbara (1950). British Medical Journal, 1, 211. Davison, M., Aries, L. J., and: Pilot, I. (1939). Surg. Gynec. Obstet., 68, 1017. Taylor, H. (1946). Lancet, 2, 441. -(1951). Ibid., 1, 7. Trinca, A. J. (1947). Med. J. Aust., 1, 385. Visick, A. H. (1946). British Medical Journal, 2, 941.
G. ALLEN, M.D., B.S., D.T.M.&H. Pathiologist, St. James's Ifospital, Wandsworth; formerly Pathologist, Suittonz and Cheatmn Genieral Hospital AND
C. F. CRITCHLEY, T.D., M.S., F.R.C.S.
Conzsul(tinzg Surgeon, Sitttoni antd Cheanzi General Hospital
The aetiology and treatment of macrocytic anaemia have in recent years been the subject of much investigation, both clinical and experimental. The following case of macrocytic anaemia cured by surgery gives support to the experimental conclusions.
of resection of the small bowel. It seemed probable that this anaemia is due to an unaccustomed dietary regime and to the hurried passage of the bowel contents in the changed circumstances. In fact, however, experimental resection of varying lengths of the gut, including in some cases the stomach, failed- to produce a macrocytic anaemia in animals. Miller and Rhoads (1935.), working on dogs, succeeded in producing only " a mild hypochromic anaemia," while Brown (1938) concluded that " resection alone did not lead to diarrhoea, anaemia, or paralysis." Wintrobe et al., (1939) found that removal of the duodenum with a portion of the jejunum in addition to the stomach resulted in microcytic anaemia. Jensenius (1945) reviewed the literature and carried out a carefully controlled series of experiments on dogs. He concluded that resections of the terminal ileum may be followed by a macrocytic anaemia or a tendency to such. It therefore seemed that lesions of the proximal gut would tend to produce a microcytic anaemia, and that. lesions of the distal bowel would tend to produce a macrocytic type. Seyderhelm et al. (1924), by inducing fibrous strictures of the terminal ileum, were able to produce a macrocytic anaemia in two of seven dogs that survived the operation. They decided...
References: Barker, W. H., and Hummel, L. E. (1939). Bull. Johns Hopk. of headache, which was later associated with severe upper substernal pain. After one week in bed he felt better. .Hosp., 64, 215. Three weeks later he was readmitted to hospital followBrown, M. R. (1938). J. clin. Invest., 17, 529. Cartwright, G. E., Wintrobe, M. M., and Humphreys, S. (1946). ing a recurrence of the pain., Clinaical findings suggested the J. Lab. clin. Med., 31, 423. presence of a pericardial effusion. In particular, the apex Dyke, W. J. C., Hind, H. G., Riding, D., and Shaw, G. E. beat could not be seen or felt and the area of cardiac (1950). Lancet, 1, 486. dullness was greatly incrtased. The heart sounds were Faber, K. (1897). Bert. klini Wschr., 34, 643. Jensenius, H. (1945). Results of Experimental Resection of Stnall notably, faint. An electroc,6diogram sho 'wed no abnormality. Screening revealed a grossly enlarged heart shadow Intestine on Dogs. Copenhagen. Miller, D. K., and Rhoads, C. P. (1935). J. clin. Invest., 14, 153. with little movement. The lung fields were clear. A needle Seyderhelm, R., Lehmann, W., and Wichels, P. (1924). Klin. was inserted in the fifth left intercostal space, 1 in. (2.5 cm.) Wschr., 3, 1439. medial to the anterior 'axillary line, and 300 ml. of greenishTonnis, W., and Brusis, A. (1931). Dtsch. Z. Chir., 233, 133. yellow opalescent fluid removed. This contained lymphoWatson, G. M., Cameron, D. G., and Witts, L. J. (1948). cytes and polymorphonuclear leucocytes in equal numbers Lancet, 2, 404. Wintrobe, M. M., Samiter, M., and Lisco, H. (1939). Bull. and was sterile on culture. The effusion recurred during the next three days, but by the end of a week had receded Johns Hopk. Hosp., 64, 399. to normal. Three weeks later he complained of substernal pain and have recurred. ' small In the annual report for 1949 of the Medical Department the effusion was found to also noted-a newAfeature. rightThe Protectorate there is a description of the sided pleural effusion was of the Uganda about the state pericardial fluid had the same characteristics as before. The methods by which information is obtained symptoms and signs ' gradually receded over the next five of public health in the Protectorate. Some of the notifica- days. tions of deaths and of infectious diseases are made by chiefs He remained well until the beginning of February, 1949of tribes, and, though the total deaths notified in this way are reasonably accurate, the allocation of deaths to the an interval of two 'months. On this occasion the effusion on for primary cause leaves much to be desired. The compiler appeared time. the day after he 'had been allowed up also Bilateral small pleural effusions were of the report writes: "While the infectious diseases are the first generally diagnosed accurately, many deaths from 'old present. He improved with rest. At this point he was given age, ' 'chest, ' or ' njoka ' (literally, a snake in the stomach) 1 g. of streptomycin daily for eight days. He has had no afford little information about the real cause of death. Less episodes of pericarditis since. He was last seen on December 19, 1949, when there than one-twentieth of all deaths occur in Government hospitals, 'and it- is rare for deaths outside to be attended by was no clinical or radiological evidence of pericardial or subphrenic disease. medical practitioners."
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