THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION

1917 Journal of the American Medical Association  
Subscription price ..... Five dollars per annum in advance Contributors, subscribers and readers will find important information on the second advertising page following the reading matter SATURDAY, MARCH 24, 1917 THE TOXEMIA OF INTESTINAL OBSTRUCTION The nature of the toxemia of intestinal obstruction has been a subject of interest and debate in the past few years. The clinician has the problem presented to him in practice repeatedly in most acute forms; the laboratory worker is perplexed by
more » ... r is perplexed by the apparently irreconcilable conflicts of experience and experiment. The concentration of the energies of a number of capable American investigators on the questions raised is certain to bring clarity into the matter before logn; indeed, the accumulating evidence begins to show that more than one factor undoubtedly is responsible for the death from obstructed intestine. When the great mass of experimental data is once critically evaluated, a rational explanation is likely to be forthcoming.. In the past, individual schools have dwelt too exclusively on a single aspect of the problem. Three classic explanations were early devised for death in obstruction: first, infection; second, nervous reflexes; third, intoxication. The last explanation has been advanced in two forms, intoxication being explained as due to noxious substances of bacterial origin in the obstructed bowel, or as the result of an actual toxic secretion by the glandular structures of the alimentary tract. Whipple,1 who has been prominent in the study of this problem, has advanced the theory that the intoxication of intestinal obstruction and closed intestinal loops is due to the absorption from the intestinal mucosa of a definite proteose. lie believes that the evidence for the intervention of bacteria in the situation is not at all conclusive, whereas there can be no question that the intestinal mucosa is essential to the production of the poison. Bacteria alone cannot form it. A recent contributionstimulates interest anew, and is likely to provoke further critical discussion of the question. In confirmation of the results of previous investigators, it has been found that dogs with an isolated closed loop of duodenum or jejunum die in from fortyeight to ninety-six hours, in most cases with perforation of the isolated loop and general peritonitis. But there is usually no excessive vomiting and hence no fatal dehydration of the body tissues. The dehydration factor has been made responsible by some of the investigators for the severe symptoms of intestinal obstruction. When the isolated and closed loop of the jejunum is sterile, complete occlusion of the blood vessels to the isolated loop has no effect on the dog; but if the loop is not sterile, the occlusion of the circulation in the loop causes death in from twenty-four to forty-eight hours with the usual symptoms of complete intestinal obstruction. An abundant series of experimental observations has seemed to the Chicago physiologists to warrant the following conclusions : Closed intestinal loops in which the bacteria are first removed are not incompatible with life. Closed intestinal loops in which bacteria are present but in which tissue necrosis is prevented are not incompatible with life. Closed aseptic intestinal loops in which the blood supply is completely shut off are not incompatible with life. The normal secretions of the duodenum and jejunum are not toxic when allowed to drain into the abdomen cavity. These results, we are reminded, do not support the theory of Draper of a normal toxic secretion of the duodenal mucosa, neutralized by the jcjtmal mucosa, or the perverted secretion theory of Whipple. In obstructed loops of bowel, occlusion of the circulation by distention from accumulated secretion may easily arise. Necrosis follows, and bacterial toxemia completes the story. Thus the Chicago investigators conclude that bacterial activity plus the necrotic tissue or the result of the action of bacteria on necrotic tissue are the important factors in the rapid death in simple closed intestinal loops. THE PANCREAS AND MUSCLES IN SUGAR METABOLISM In the current of the sciences, just as in the life of man, von Fürth1 wrote not long ago, there are periods when every good intention and the most honest effort are insufficient to make any decisive and productive progress possible ; evil days when ability is compelled to employ a good part of its innate energy to keep from sinking into dejected inefficiency. Then suddenly some new event changes the situation and brushes aside the impediments which have opposed the free development of the long accumulated latent energy. At once a period begins of heightened, feverish activity which endeavors to make up for all that was missed in the dull times of stagnation. The discovery of the relation of the pancreas to diabetes represents one of these unusual events. Since its announcement in 1889 there has been the liveliest discussion as well as a truly enormous amount of inves-1. Whipple, J.
doi:10.1001/jama.1917.04270030246017 fatcat:qwvrq3htzbeihk52qd22zo5qwa