W. J. Merle Scott

Spinal anesthesia in the treatment of megacolon and obstinate constipation

P RIOR to 1927, the treatment of idiopathic megacoIon was varied and extremeIy unsatisfactory. The conservative treatment consisted of diet, catharsis and repeated enemas. The resuhs were far from encouraging and after a Iong tria1, many of these cases were treated surgicaIIy. The surgica1 treatment was attended with radica1 procedures and high mortaIity. The more radica1 procedures varied from coIostomy, partia1 coIectomy to tota extirpation of the coIon. Even after such formidabIe procedures, the resu1t.s were often poor. Various theories have been advanced as to the cause of idiopathic megacoIon ranging from adhesions on the outside of the bowe1 to vaIve formation within. Briefly, some of these theories wiI1 be mentioned. An abnormaIIy Iong mesentery, chronic coIitis, increased Iength of the coIon, actua1 mechanica obstruction and congenita1 aplasia of the muscuIar tunics, were the outstanding theories unti1 rgoo. At that time Fenwick considered the possibiIity of spasm of the sphincter ani associated with fissures in the ana margin. In rgo7, Bing considered a neuropathic diIatation and hypertrophy of the coIon, probabIy a segmenta defect associated with changes in the sympathetic nerves. The true definition of idiopathic megacoIon infers a diIatation of the bowe1 without any obvious mechanica obstruction inside or outside of the bowe1. If we are to adhere to this definition, many of the theories, by the nature of their expression inferring some mechanica obstruction, cannot be considered in a discussion of idiopathic megacoIon. In 1895, Langley and Anderson showed that stimuIation of the Iumbar sympathetic gangIia caused an inhibition of peristaIsis with diIatation of the coIon and contraction of the interna sphincter of the anus. GaskeII feIt that impuIses inhibitory to the muscuIature of the Iarge bowe1 and motor to the interna sphincter of the anus pass through the Iumbar sympathetics. Learmouth and Markowitz have since substantiated this opinion by pIacing a buIb against the interna sphincter and recording contractions foIIowing stimuIation of the gangIia. In 1924, RoyIe and Hunter removed the Iumbar sympathetics for reIief of spastic paraIysis of the Iower extremities. They noted that one of the benefits of the operation was the striking reIief of the obstinate constipation that had been present in these patients. It was not unti1 1926, however, that a practica1 appIication of these observations was made when Wade and RoyIe performed a Iumbar sympathectomy for Hirschsprung’s disease (idiopathic megacoIon). The child made a fine recovery with exceIIent cIinica1 improvement and reIief of the constipation. In 1928, Judd and Adson reported 2 cases and in 1930, Scott and Morton reported one case. Since then numerous cases have been reported with varying degrees of success. The next step in the treatment of the disease was the introduction of spina anesthesia as a preoperative test to determine whether sympathectomy wouId be of benefit. This test was used prior to sympathectomy in the case reported by Scott and Morton. The resuIts were striking.

Effect of Extract of Adrenal Cortex upon Thymic Weight and Resistance to Bacterial Intoxication in Chronic Adrenal Insufficiency.

Extirpation of both adrenal glands is rapidly fatal in most laboratory animals. However this operation seems to have little effect for several weeks upon the physical condition of the majority of rats submitted to it. But such apparently healthy survivors manifest at least 2 important differences from normal rats, an increased susceptibility to bacterial intoxication, 1 and hypertrophy of the thymus. 2 In each instance the variation has been correlated with a functional deficiency of the adrenal cortex rather than of the medulla. It is our purpose to report the effect of an extract of the adrenal cortex upon this chronic type of adrenal insufficiency, using as criteria the resistance of the animals to bacterial intoxication and the size of the thymus. Fifty-eight rats from 5 litters born on the same day were used. These were divided into 3 groups and sampled for the different groups according to the method adopted by Dr. Luce Clausen, 3 insuring equal distribution of weight and equal representation of the different litters in each group. At the beginning of the experiment the mean actual weights of the 3 groups were as follows: Each of the first 2 groups contained 19 members. Group 3 was used for control determinations of body weight and thymus weight and was subdivided into 2 similar parts of 10 members each, one of which (A) received the injection of typhoid vaccine and the other (B) did not. All members of Groups 1 and 2 were doubly adrenalectomized on the same day and were injected subcutaneously with 1/2 cc. of fluid twice daily for 2 weeks after operation. Group 2 received an extract of the adrenal cortex made and kindly supplied to us by Drs. W. W. Swingle and J. J. Pfiffner, 4 while in Group 1 the same amount of Ringers solution was used.

Obliteration of Vasoconstrictor Gradient in the Extremities Under Nitrous Oxide-Oxygen, Ether, and Tribromethyl Alcohol Anesthesias.

Recent studies of peripheral vascular diseases have brought out the importance of differentiating the element of spasm from that of organic occlusion. Vasoconstriction can be demonstrated in the extremities of most individuals with normal blood vessels by measuring the surface temperatures. This action is present in varying amounts depending on the interplay of environmental conditions and the nervous mechanism. It possesses a definite gradient 1 so that it usually begins about the knee and progressively increases distally. Consequently the toes are normally the coldest parts of the lower extremity. These surface temperature differences can under certain conditions be made to disappear. In a series of 22 individuals with normal vessels it was found that this took place when the lumbar sympathetic fibres were paralyzed by spinal anesthesia. All surface temperatures of the extremities came to approximately the same level, with a variation of ±1.7°C. from the mean. This evidently represents a condition of physiological vasodilatation in the vessels of the extremities and we have called it “the normal vasodilatation level.” Its importance consists in that it permits an accurate estimate of the degree of spasm in any given case of vascular disease. The failure to react to the normal level in the latter signifies the presence of organic occlusion, the degree of which is measured by subtracting the maximum temperature achieved from the normal vasodilatation level. Having established the response to known regional sympathetic paralysis, we now report the effect of certain general anesthetics upon the vasoconstrictor gradient in order to simplify if possible the methods for gaining this information. We have found that nitrous oxide-oxygen, ether, and tribromethyl alcohol individually in anesthetic doses will completely obliterate the vasoconstrictor gradient.

The effect upon gastric secretion of introducing dilute hydrochloric acid into the duodenum. A study of normal humans and duodenal ulcer patients.

HC1 in 0.4% solution or in gastric juice, when introduced into the duodenum of normal subjects, had no constant, significant effect on gastric secretory curve.

CHANGES IN THE VASOMOTOR REACTION ASSOCIATED WITH GLOMUS TUMORS

The interesting clinical syndrome produced by tumors of the glomic structures in the extremities was first described by Masson in 1924 (1) and called by hlim, gloiinus tumors. WVe lhave collected from the literature seventy-four cases of this condition (Table I). This condition is easily

Expulsion of its Contents as a Function of the Gall Bladder.

Since the introduction of methods that visualize the gall bladder, many opinions have been expressed as to the mechanism of its emptying. These can be divided into 2 groups: (a) that the gall bladder has a passive rôle in this process, and (b) that the gall bladder empties due to the contraction of its own musculature. We wish to present further evidence that expulsion of its contents is an inherent function of the gall bladder and acts independently of purely mechanical factors. The chief extrinsic agencies suggested as causing the discharge of bile from the gall bladder are: (1) variations in intra-abdominal pressure, (2) intestinal peristalsis, (3) elastic recoil following relaxation of the common-duct sphincter, and (4) the washing out of the gall bladder by hepatic bile. (1) The fact that the gall bladder may remain full for many days during fasting and that violent struggling associated with tube feeding in the cat produces no discharge of its contents 1 is sufficient evidence that variations in intra-abdominal pressure, within physiological limits, do not cause emptying of the gall bladder. (2) Vigorous intestinal peristalsis produced by physostygmine as well as the normal movement of a barium meal through the intestine without effect upon the gall bladder containing iodized oil, 1 would seem to rule out intestinal peristalsis as a significant factor. (3) Though the common duct be completely excluded, a fat meal will induce emptying of the gall bladder through a cannula in the cystic duct (Copher 2 ), or the cut end of the common duct (Boyden 3 ). Also in one of our cats whose gall bladder had been filled with iodized oil, the hepatic and common ducts were injected from the gall bladder after the ingestion of fat without the discharge of any of the oil inta the duodenum.