CharlesWatson Macgillivray
1907 The Lancet  
anæmia may be due to some change in the condition of the blood-such as loss of haemoglobin, diminution in the number of the red blood corpuscles or both combined-that so affects the relationship between the salt retained in combination with colloid and the salt free to be eliminated that a much larger proportion of the salt is retained than in normal circumstances. This view would exonerate the kidneys from blame and lay the fault on the condition of the blood. What evidence is there in favour
more » ... is there in favour of this view ? In the first place, it is a remarkable fact that it is in the chronic parenchymatous form of nephritis that the salt retention and low excretory quotient are best seen, and it is in this form also that the anaemia of Bright's disease is well marked. Then from an analysis of the results of observations in anaemic conditions due to different causes the concentration of the serum varies directly with the amount of cedema present and with the degree of anæmia, as shown in Table VI. TABLE VI. These results contrast very markedly with those shown in Table V ., in which, even with general oedema and ascites but no anaemia, the concentration of the serum and excretory quotient conformed to the normal. Of course, a much larger number of observations will be necessary before any definite conclusion can be arrived at, but all our evidence would seem to point to the fact that the degree of concentration of the serum determines the degree of oedema, and that there is some relationship between the oedema and the amount of anaemia. This appears to be true equally for secondary anaemias (probably also all anaemias) and the anæmia of Bright's disease. It would, therefore, follow that the excretory quotient test, being a measure of the salt concentration of the serum compared with the salt concentration of the urine, does not depend on the presence or absence of kidney disease, whereby the kidney is unable to eliminate the chlorides, but does depend on some condition of the blood or tissues by which chlorides are retained in the system. What the determining factor in this retention is at present it is not possible to say ; it would appear at least to have some relationship to the presence and degree of anasmia, but whether due to destruction of corpuscles, loss of haemoglobin, or some other factor must remain for the present an open question. Methods of investigation.-When dealing with blood containing a low percentage of hæmoglobin a modification of Wright's method had to be adopted, as in these cases the colour changes on dilution differ so slightly that precision could not be attained. The translucency of hasmolysed blood was taken advantage of and the point where haemolysis occurred was determined by the ease with which a black dot on a white ground could be seen through blood that had been haemolysed compared with the nontranslucency of even very diluted blood that had not undergone haemolysis. In each observation the blood examination was carried out by an independent worker, Assistant-Surgeon L. M. Ghosal, L.M.S. ; also the amount of chlorides present in the urine was determined by another assistant, Assistant-Surgeon M. M. Dutta, L.M.S., to both of whom I offer my best thanks for much assistance. For permission to examine the different patients I am indebted to Colonel C. P. Lukis, I.M.S., principal ; and Colonel G. F. A. Harris, I.M.S., Captain J. W. D. Megaw, I.M.S., and Captain M. MacKelvie, I.M.S., physicians of the Medical College Hospital, Calcutta. Last, though not least in degree, my thanks are due to the students of the physiological classes for providing the means of determining the physiological standards on which the whole value of the paper rests. Calcutta. SENIOR ORDINARY SURGEON TO THE ROYAL INFIRMARY, EDINBURGH. THE following case seems to possess some points of interest, in fact to be perhaps unique in certain respects, and therefore deserves to be recorded. Towards the end of January of this year an infant was sent to my wards in the Royal Infirmary, Edinburgh, as a case of tuberculous peritonitis requiring surgical interference. The mother, a woman aged 35 years, gave the following history. When she was about 20 years of age she married and had one child, a boy, who died. She was afterwards left a widow, but subsequently she again married and had five consecutive miscarriages, at periods varying from four to seven months. No syphilitic history could be made out. Finally, at the commencement of February, 1906, she was safely delivered, at full term, of a healthy female child who was entirely brought up on the breast. The child throve well until she was three months old. The mother then noticed that the abdomen was hard and full, and that the infant seemed to suffer pain and discomfort, and was occasionally sick and troubled with diarrhcea. From this time onward the abdomen rapidly increased in size, while the child wasted. She grew peevish and took nourishment badly, had increasing difficulty in breathing, and the former symptoms of digestive disturbance got steadily worse. The mother finally sought medical advice, and the child was sent to the Infirmary with the diagnosis previously mentioned. On admission the child was found to be an ill-nourished and emaciated infant, with cyanosed lips and face, rapid pulse, difficult breathing, and some sickness and diarrhœa. The abdomen was enormously distended, the lower ribs were projecting, the parietes were thinned and showing numerous large distended veins, and the navel was projecting. The whole abdomen was of drum-like hardness, so that nothing could be felt of its contents. There was absolute dulness on percussion, except in the left flank, where there was a tympanitic area. Slight, varying areas of tympanites could be made out on light percussion to the right of the umbilicus. The dulness extended up to the right nipple, and a circumscribed area of tympanites was to be made out below the left nipple. About a tablespoonful of clear yellow fluid was drawn off by means of a hypodermic syringe from the right flank and half a teacupful of similar fluid from the left of the umbilicus. The fluid did not flow easily ; on moving the needle in different directions it seemed to penetrate separate cavities. The distension being slightly relieved, the surface of the underlying structures appeared to be irregular and nodular. No more definite diagnosis could be made than that the abdomen, from the diaphragm to the pelvis, was filled by a mass containing separate cavities filled with fluid, and that the greater part of the intestines lay in the left flank with a single coil passing upwards to the right of the umbilicus. Two days later the child was chloroformed in a warm theatre and an exploratory incision was made a little to
doi:10.1016/s0140-6736(00)68183-7 fatcat:2ykfdtsyn5akbatyqho5f5oksy