Postgrad Med J: first published as 10.1136/pgmj.26.291.24 on 1 January 1950. Downloaded from

24

CONGENITAL PYLORIC Together with Reports of Two Cases of, Duodenal and One Case of Jejunal Atresia By DAVID LEVI, M.S., F.R.C.S.

The aetiology of congenital pyloric stenosis re- operated on three brothers successively in the mains unknown. The theory at present fashion- same family. able is that the development of the neuro-muscular plexus has been delayed and that the pyloric Pathology sphincter fails to relax and consequently hyper- The shows a generalized hypertrophy trophies. The fact is that the whole musculature of the whole musculature reaching an extreme of the stomach is hypertrophic. This hyper- degree at the . The transition from the trophy is not present at birth, but appears with thickened muscle of the stomach to the thin considerable rapidity in patients presenting symp- is abrupt. The circular fibres of the toms. The following case history shows that the pyloric sphincter are most affected. hypertrophy is acquired rather than congenital:- Viewed from the duodenal side, the hyper- The author was asked to operate on a child trophic Sphincter has been likened to a small aged ten days, both of whose brothed had been cervix, but it does not project into the duodenum operated on by him for pyloric stenosis. The as the cervix projects into the vagina. The fold of mother and the maternity nurse were certain that duodenal mucosa at the junction of the duodenumby copyright. this child had the same trouble. No tumour was has been called the dangerous angle and may be found on examination or at operation and the injured at operation. stomach appeared to be perfectly normal. The With the persistent and failure of food abdomen was therefore closed without further to reach the , the blood chemistry procedure. Three weeks later the abdomen was is seriously altered. The blood urea rises, the re-opened on account of persistent symptoms and alkali reserve is increased, the urine is diminished on this occasion a well-formed tumour was present. in quantity and its chlorides diminished or absent. The muscle was therefore divided in the usual The alkalosis is caused by the persistent loss of acid manner and the child made a good recovery. radicles in the vomit, whilst the blood urea is http://pmj.bmj.com/ Babies suffering from pyloric stenosis are now raised by the combination of starvation and brought to hospital comparatively early in the vomiting. course of the disease. The starved infants of In a child which has died from the disease the former years are now rarely seen. We hope that stomach is hypertrophic, the hypertrophy ex- more children are breast-fed. The truth of the tending up to the oesophageal opening. It is most saying that ' breast milk never disagrees with a marked at the pylorus. The gastric mucosa shows baby' is generally recognized. The teaching that changes caused by the associated . There

'if a breast-fed baby vomits persistently, it may be ' coffee ground' content inside the organ. on September 25, 2021 by guest. Protected probably has pyloric stenosis-look for it' is The body generally shows signs of , bearing fruit. alkalosis and starvation. Apart from the effects of The disease occurs more frequently in males and these pathological and biochemical changes the usually manifests itself in infants between three body and organs are normal. and eight weeks old. It may commence earlier. One child in this series vomited from birth. If an Symptoms and Signs infant with pyloric stenosis reaches the age of The first symptom is vomiting. This is com- three months without operation, the condition is monly projectile and comes on after feeding. The said to undergo spontaneous resolution. This is vomit never contains . It persists and is not absolutely true as operation was necessary for associated with and loss of weight. one child of five and a half months (Harris, C., In the later stages the vomit may contain blood 1938, Proc. Roy. Soc. Med., 31, 767). The babies coming fromthe inflamed gastric mucosa. If a new- are always hungry, alert children and the con- born child vomits and the vomit is bile-stained, dition may occur in several members of the same the child is not suffering from pyloric stenosis but family. As already indicated, the author has may be suffering from intestinal obstruction. The Postgrad Med J: first published as 10.1136/pgmj.26.291.24 on 1 January 1950. Downloaded from

Yanuary I1950 LEVI: Congenital Pyloric Stenoiis 25 obstruction may be in the duodenum, as in persistently. It will become alkalosed, having , or anywhere down the intestinal lost many of its chloride radicles in the vomit. tract as far as the anus. New-born babies may Later the vomit may contain blood coming from vomit because of a tight anus, not necessarily a the inflamed gastric mucosa. The blood urea complete atresia; or there may be some other rises and one case under the author's care had a cause for the vomiting. blood urea of 98 mg. per ioo cc. of blood. It To examine such a child the physician should made a good recovery after operation and is now wear a mask to prevent cross-infection, arid should 14 years old. have warm hands. The child should be in a warm The advanced stages of the disease are now room and a sterile feed should be available as fortunately rarely seen. The picture is unmistak- well as a sterile finger stall. The abdomen is un- able. The infant is emaciated, bluish grey in covered and inspected. Often if the sterile finger colour, with bright eyes and loose skin which stall is put on the index finger of the right hand hangs in folds from the abdomen and thighs, and it and this is placed in the baby's mouth the firm is constipated to an extreme degree. pyloric tumour will be felt mid-way between the ensiform and the umbilicus, just to the right of Treatment the mid-line. Marked segmentation of the rectus The treatment of hypertrophic pyloric stenosis abdominis, the edge of the liver, or the right is surgical, provided that there is an efficient kidney may give misleading evidence. The act surgical team and correct nursing and hospital of sucking stimulates gastric ; the facilities. The place for medical treatment in pylorus will contract and become palpable. The pyloric stenosis is at the onset of symptoms when tumour becomes hard and soft. If a tumour is the diagnosis is still in doubt, or when efficient felt, the diagnosis is assured. If the finger stall surgery is not obtainable. Once the diagnosis is method is not successful a feed should be given. made, valuable time should not be wasted in Whilst the child is drinking, the abdomen is medical measures; the surgeon should be con- palpated and the tumour should become palpable. sulted at once. by copyright. As the stomach fills, peristalsis may be seen passing There are three components to the surgical from left to right; often the whole outline of the team. The special hospital, the nursing staff and stomach is visible. Gastric peristalsis may be the surgeon and house officers. For perfect visible in children who are not suffering from results the three must work together. The hospital pyloric stenosis and by itself is of no diagnostic should have separate rooms for nursing mothers value. Associated with a palpable tumour, how- and their babies. If the baby is bottle-fed the ever, it clinches the diagnosis of pyloric obstruc- child must have a room to itself. Everything that tion. Finally, the child may vomit in characteristic goes into the room must be sterile. All visitors, fashion at the end of the feed. Should there still attendants and maids must be free from colds and be doubt about the diagnosis, the stomach should their throats must be free from haemolytic http://pmj.bmj.com/ be aspirated before each feed. A persistent gastric streptococci. Children must not have soiled residue is suggestive of pyloric stenosis. napkins changed at feeding times. The nurse Help may also be obtained by an X-ray examina- changing the child must regard this operation in tion. Infants take a barium meal quite well; it the same way as she would regard i surgical can be given by spoon feeding or can be run into dressing. She must scrub up before and after- the stomach through a catheter. As barium is apt wards. The soiled napkins must be put into a

to lodge and remain in the colon becoming hard covered sterilized receptacle and sent away. The on September 25, 2021 by guest. Protected and inspissated and even giving rise to obstructive soiled squares must not all be tipped into an open symptoms, however, it is seldom used in the in- dustbin kept under the kitchen sink as was the vestigation of such infants. A lipiodol meal is custom in a certain hospital 25 years ago. preferable. The only necessary pre-operative treatment is a A large stomach with gastric delay is the usual gastric lavage to empty the stomach of its retained finding, although occasionally an opaque meal will contents and air. It is not the author's routine pass the pylorus in these infants. Sometimes it practice to give pre-operative fluids by other is possible to demonstrate the long thin pyloric routes than the mouth. No absolutely dogmatic canal running through the sphincter.* The statement can be made. If a child is grossly stomach is often very mobile and large peristaltic dehydrated, intravenous fluids are given pre- waves can be seen passing along it. In most cases operatively. it should be possible to make the diagnosis on the Donovan (I946, Ann. Surg., 708, I5) states that history and examination without recourse to the pre-operative preparation is the greatest factor in X-ray department. bringing the mortality to its present level and given Should the child be neglected, it will vomit ' 8o ml. of physiologic salt solution with or Postgrad Med J: first published as 10.1136/pgmj.26.291.24 on 1 January 1950. Downloaded from

26 POSTGRADUATE MEDICAL JOURNAL january I950 without dissolved glucose twice a day under the the gradual resumption of normal feeding with skin.' This would be equivalent to giving i pt. of special care to guard against the risk of gastro- fluid subcutaneously to an adult, and as can be . If the child has been recently taken from imagined would be by no means conducive to the breast, every endeavour is made to re-establish comfort. The fluid would be better taken by mouth. By efficient surgery, infants suffering PYLORIC STENOSIS POST-OPERATIVE FEEDING from pyloric stenosis are enabled to do this. Gastric lavage should be carried out a quarter I. Breast Feeding. For the first two days expressed mother's niilk is used. The child is not put to the breast of an hour before operation. The nurse should until two to three days after operation, as its condition make sure that the stomach is emptied of air as allows. Feeds commence 34 hours after operation. well as fluid. If the child is not disturbed by the Hours catheter, it may be left in place during the opera- after oz. dr. Feeds tion, to enable any air swallowed subsequently to Operation be extracte4. One minim of tincture of opium 3j .. I 7.5% glucose in water may be given if the child is at all restless. 4 * * I ,. .. , 4i ** I ,, ,, , , 5 . I ,, , Operation 5i .. I 7.5%/ glucose water + i dr. should breast, milk The temperature of the operating theatre 6+ .. I 7.5% glucose water + Idr. be as near to 800 F. as possible. If necessary, the breast milk child may be placed on the operating table on two 7 .. I 7.5 % glucose water + dr. partially filled rubber hot water bottles. The breast milk temperature of the water in the bottles should be 9 .. 3 Breast milk Iio * 4 ,, ",, tested with a thermometer and should be 98.40. 12 . 6 ,. Local anaesthesia is invariably used and is pro- 13A I 0 ,. .. duced by means of A per cent. ethocaine with or Ij I O without adrenaline. by copyright. A general anaesthetic is neither necessary nor z7 .. I 2 ,. desirable. The child is less distressed by the pro- 2i . . I 4 ,. .. cedure and is able to take fluid by the mouth earlier after local anaesthesia. Never more than 302 . I 4 ,, 33 I 6 , IO ml. of the anaesthetic are required; 2 to 3 ml. 361 .. I 6 ,. are placed subcutaneously along the line of the 391 2 0 ,. .. proposed incision. A little less than this is divided Thereafter three-hourly feeds. between the muscles on either side. The remain-

ing 2 tO 3 ml. are placed deep to the linea alba in 2. Bottle Feeding. http://pmj.bmj.com/ the extra-peritoneal space. The whole procedure Hours can be carried out through one or two skin after oz. dr. Feeds punctures. Operation A mid-line incision is found to be most satis- 34 .. 7.5% glucose be to leave the 4 . . I ,., . factory. Nothing should allowed 44 . . I ,., . abdomen other than the hypertrophic pyloric 5 I ,., . tumour. This can be delivered by the use of two 54 . I ,., . pairs of plain dissecting forceps. It is not necessary 6 I ,., . on September 25, 2021 by guest. Protected for the operator to put any part of the hand into 64 . . I ,., . 7 * * I ,., . the peritoneal cavity. The pylorus is held between 74 . . I Half strength i cream milk the finger and thumb and is squeezed gently until 84 2 ,. ..,. it becomes hard. A line is chosen on its anterior 94 * - 3 ,. .. .. surface as free from blood vessels as possible and . . 6 Full strength E cream milk the is incised from the duodenum to I3i beyond the hypertrophic sphincter. The muscle is then split with a blunt dissector or the end of a 234 . . I 4 ,, .. .., . blunt-ended pair of scissors and the mucosa is

seen to through. Closure of the abdomen is ,, ,, bulge 2 ** I 4 ,, ' surprisingly easy as the peritoneum comes together 28 .. 2 0 ,, ,, ,, , without tension. Gentleness is more important than speed. With local anaesthesia and a warm theatre, Thereafter three-hourly feeds of 3 oz., increasing speed is of little moment. gradually according to the child's weight. The essentials of after-treatment consist of Small quantities of water allowed between feeds. Postgrad Med J: first published as 10.1136/pgmj.26.291.24 on 1 January 1950. Downloaded from

Yanuary I950 LEVI: Congenital Pyloric Stenosis 27 breast feeding. This is done to minimize the risks CONGENITAL DUODFNAL ATRESIA of gastro-enteritis to which bottle-fed babies are Duodenal atresia differs from hypertrophic much more prone. During the author's life, pyloric stenosis in that it causes symptoms from gastro-enteritis has been the cause of the post- birth; vomiting comes on immediately. The operative mortality. Oral streptomycin in associa- children are apathetic and sleepy. tion with other medical measures is of value should There are two clinical groups into which these a bottle-fed child develop diarrhoea. patients fall, the first in which the obstruction is Appended are post-operative feeding charts complete, the second in which it is only partial, and which are in use at the present time at the West- two pathological groups, intrinsic and extrinsic. minster Children's Hospital. The intrinsic form is a malformation of the duodenum consisting of either (i) a complete dis- continuity of the bowel, (2) an atresia, the two THE INFAJ4TS HOSPITAL ends of the duodenum being linked by a fibrous WEIGHT CHART. cord which may or may not have a small lumen, or NameiHNT K0IN& (3) the presence of a septum across the duodenum. Age 7 WE CSa Date or BLrth24 11 49-B.rth We.ght 81i I. These malformations may occur either proximal or distal to the bile papilla. If proximal, the DAE rA lq*. vomitus contains no bile; if distal, it is bile- C- stained. The latter, distal obstruction, is com- moner in the proportion of 5: I. . 1IJ .J2: .-- Extrinsic obstruction is due to malrotation of .; the gut, being produced by a , or by peritoneal bands and adhesions resulting from the

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Children treated in this way make excellent recoveries. Fig. i is a typical weight chart. Ten years ago the author published a consecutive series ot Ioo breast-fed babies suffering from pyloric stenosis operated on at the Wesminster Children's

jiMM on September 25, 2021 by guest. Protected Hospital without a death. The war intervened. Since then a further 47 cases have been operated on by him at that hospital without fatality. Of these 47, 28 were breast-fed, i9 bottle-fed; 40 were males, 7 females. One case suffered from erythroblastosis foetalis, whilst one case developed gastro-enteritis and a urinary infection- after operation. Between the years I934 and I948, a further 50 cases were operated upon by him at the Luton Children's Hospital; 39 were males, ii females. None of these cases was given fluids pre-opera- tively except by mouth. All were operated upon FIG. 2.-The intestine from duodenum to mid- on the day the diagnosis was made. There were transverse colon lies outside the abdomen in the again no deaths. umbilical cord. Postgrad Med J: first published as 10.1136/pgmj.26.291.24 on 1 January 1950. Downloaded from 28 POSTGRADUATE MEDICAL JOURNAL January I950

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FIG. 3.-The loop takes a half turn anti-clockwise. FIG. 4.-At the beginning of the tenth week the gutby copyright. returns to the abdomen, the pre-arterial loop going back first.

At an early period of development the intestine survive indefinitely. Physical examination may re- from the duodenum to a little to the left of the veal an active stomach but is otherwise negative, mid-transverse colon is suspended from the and unlike in hypertrophic pyloric stenosis, an posterior abdominal wall by mesentery and is X-ray examination may be of the greatest value. situated outside the abdomen in the umbilical No time should be wasted in trying alterations in cord (Fig. 2). The loop thus formed has an feeding. The Health Service has put a mobile artery running down the centre of its mesentery- X-ray plant in reach of every home. It should behttp://pmj.bmj.com/ the superior mesenteric artery. This loop takes a used. half turn to the right (Fig. 3). At the begiAning Barium need not be given for the gas shadows of the tenth week the gut returns to the abdomen, may show all that is needed. All babies are born the pre-arterial loop going back first (Fig. 4), without air in the gastro-intestinal tract, but they followed by the post-arterial loop and finally by soon swallow air which appears first in the stomach the caecum. The caecum then descends into the (Fig. 6), then in the small gut and finally in the

right iliac fossa and the areas of ' peritoneal fixa- colon (Fig. 7). This march of the air which on September 25, 2021 by guest. Protected fion' fuse (Fig. 5). Failure at any stage of this occurs within the first few hours of life is of great process leaves the way open for a large number of diagnostic value and all babies who vomit at birth variations of malrotation of the gut, and malrota- should be X-rayed. Often this one examination tion may give rise to intestinal obstruction by will pinpoint the site of the intestinal obstruction means of volvulus, kinjing or obstruction by bands (Fig. 8). The diagnosis can be confirmed by and adhesions. using a contrast medium, but if barium is used Such infants vomit persistently soon after birth. and the lesion is in the small gut, the inspissated In both the author's cases reported here the vomit barium in the gut may present a problem and may contained bile, indicating that the obstruction was in itself produce obstruction. A lipiodol meal is distal to the bile papilla. Meconium is passed at preferable. first but in children with a complete obstruction, Operation should be undertaken as soon as the stools soon cease except for a little mucus. De- diagnosis is established. hydration and loss of weight supervene and death The procedure in duodenal atresia is the re- occurs in about ten days. verse of that in pyloric stenosis. A general If the obstruction is only partial, the infant may anaesthetic is essential in order to discover the full Postgrad Med J: first published as 10.1136/pgmj.26.291.24 on 1 January 1950. Downloaded from

January 1950 LEVI: Congenital Pyloric Stenosis 29

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FIG. 5.-The caecum finally descends into the right FIG. 6.-Swallowed air in the stomach and upper small by copyright. iliac fossa. intestine in a normal child I hour and 40 minutes after birth. extent of the abnormalities present. To do this, Barium Meal. No barium passed beyond it may be necessary to eviscerate the child, which second part of duodenum in one hour. can only be done under full anaesthesia. In the Laparotomy on day of admission, after gastric author's experience these children stand eviscera- lavage. tion well, shock being apparently less the younger General anaesthesia. Duodenum found to be the infant. obstructed by two thick bands in position AA In a warm theatre the child is placed on hot (Fig. 9). Duodenum appeared to be patent. http://pmj.bmj.com/ water bottles filled with water at blood heat. The Malrotation of gut present. The child passed umbilical stump looks septic but is apparently bile-stained stools six days after operation, but I2 worse in appearance than in fact. Through an days after operation developed loose stools and ample incision the viscera are delivered on to the vomiting and died a week later. abdominal wall in order to discover accurately the Post-Mortem Examination. Wasted, dehydrated nature of the congenital abnormality. A malrota- female infant. Well-healed upper abdominal tion of the gut is then corrected, whilst if the vertical incision. Some patchy collapse of the on September 25, 2021 by guest. Protected obstruction is due to a band, it is divided. Some- lungs. Thorax otherwise normal. times two lesions may co-exist. It may be Abdomen. No excess fluid. Left lobe of liver necessary to cut the peritoneum on the lateral side adherent to scar in abdominal wall. Numerous of the second part of the duodenum in order to adhesions round site of operation. Great omentum free it and follow it round. After a volvulus has absent. been reduced, there may still be a drag on the Stomach. Distended, otherwise normal. duodenum (Fig. 9). Pylorus normal. Duodenum. First and second parts distended. Case I Mucosa of duodenum and upper inch or two H.S. Admitted, September 8, 1947, aged i6 of appeared hyperaemic. Bile entered days. Full term birth, weight, 7 lb. 7 oz. pormally on pressure on gall bladder. History of melaena from second to fifth days. Duodenum compressed by band consisting of Since birth vomited bile-stained fluid one to aberrant first part of colon and root of mesentery one and a half hours after food. Weight on (Fig. 9). admission, 6 lb. i oz. Small Intestine. The root of the mesentery E Postgrad Med J: first published as 10.1136/pgmj.26.291.24 on 1 January 1950. Downloaded from s0 POSTGRADUATE MEDICAL JOURNAL 7anuary I950

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FIG. 7.-Swallowed air in the stomach, small intestine Fic. 8.-Infant held upside down, showing air in theby copyright. and colon in a normal child io hours after birth. bladder and which communicate. Diag- nosis: Rectovesical fistula with .

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FIG. 9.-Case i. Malrotation of the bowel with ob- FIG. I o.-Straight X-ray of abdomen in a case of struction of the second part of the duodenum, atresia of the second part of the duodenum, show- caused by two thick bands in the position AA. ing gross distension of the stomach and duodenum with air. None has passed on into the distal bowel. Postgrad Med J: first published as 10.1136/pgmj.26.291.24 on 1 January 1950. Downloaded from

January 1950 LEVI: Congenital Pyloric Stenosis 3' Post-Operative Treatment The child is put back to bed and is given intra- venous glucose 4.3 per cent. in saline o. i8 per cent. and the drip is continued until the child can safely take fluids by mouth. A tube is put into the stomach and continuous gastric suction is estab- lished for 48 to 56 hours. Feeding is then com- menced. The stomach contents are aspirated at first before each feed to prevent overdistension of the stomach. When gastric function is re- established the drip is discontinued. The importance of an intravenous drip in these cases cannot be overstressed. Bv its means the hydration and, to a large extent, the nutrition of the child, can be maintained during the critical period before the gastro-enterostomy begins to function. The author has previously reported two patients successfully operated on in this way (Proc. Roy. Soc. Med., I935, 29, 1213; Ibid., 1938, 31, 76I). The latter child is now ii years old, in good health and ast a preparatory school. A further recent case is appended:- Case 2

J.C. Born, July 5, I948, weighing 6 lb. 3w OZ.by copyright. Vomited bile-stained fluid from birth. First seen, July 20, I948. Weight, 5 lb. 61 oz. FIG. i i.-Case of congenital absence of a part of the Slight icteric tinge. upper , with gross distension of the stomach Barium Meal. No barium passed into the and duodenum above. jejunum in i E hours (Fig. io). Laparotomy same day, after stomach wash out. was superior to the first part of colon. Other- First and second parts of duodenum found to wise normal. Contents bile stained. No be enormously distended. Atresia of the second collapse or distension. part beyond the biliary papilla. Whole of small gut collapsed and very small. http://pmj.bmj.com/ . Ileo-colic junction lay just Posterior gastro-enterostomy performed. On re- below the pyloric end of stomach. turn to ward an intravenous drip and continuous normal. First part of colon then ran behind the gastric suction through a small catheter pet up. root of the mesentery and thereafter ran be- This treatment was continued until July 23, when neath the stomach to a normal splenic flexure. fluids were started by mouth. Drip discontinued, Descending colon normal. July 24. Breast feeding was resumed and progress Rest of abdomen normal. The child was on was satisfactory. discharged on September 25, 2021 by guest. Protected Summary. Malrotation of intestine. Enteritis. August 30, having regained its birth weight. It In cases of intrinsic obstruction of the was last seen on March 2I, 1949, in good health duodenum, either partial or complete, a gastro- and weighing 22 lb. i oz. enterostomy should be performed. This may be either anterior or posterior, depending upon the Case 3 condition found and the way in which the jejunum L.S. Admitted January 22, 1949, aged four lies most easily. A clamp may be used on the days. stomach but not on the intestine, which is very No stool since birth. Had taken small feeds small. Finest embroidery needles threaded with only which it vomited promptly. Normal preg- silk are used. For suturing the stomach to the nancy; full-term delivery. jejunum, various aids to suture have been Examination showed a dehydrated baby, thought described such as the passage of a metal-tipped to be slightly jaundiced. The abdomen was dis- tube into the stomach, and the distension of the tended, especially in the upper part; the lower collapsed small gut with air injected with a syringe. part was dull to percussion. No mass felt. The The author has not found them of value. child vomited bright yellow, mucus-containing E Postgrad Med J: first published as 10.1136/pgmj.26.291.24 on 1 January 1950. Downloaded from

32 POSTGRADUATE MEDICAL JOURNAL lanuary Io95 fluid and proceeded to pass its first'stool, con- large quantity of thin, bile-stained mucus was sisting of opaque 'gelatinous ovoids with a few aspirated. A side-to-side anastomosis was per- darker-pellets, slightly bloodstained. formed between the proximal and distal loops; Straight X-ray of the abdomen showed the go ml. of glucose saline was given into the internal presence of gas in the stomach, but none elsewhere jugular vein. in the bowel. The child's condition was satisfactory for 36 -Operation the same day under local anaesthesia hours after operation, but thereafter vomiting re- later supplemented with cyclopropane and oxygen. curred, the stomach aspirations were large and, in Grossly dilated small bowel was delivered and spite of intravenous infusions, its condition followed to a blind- end, where there was a gap of deteriorated and death occurred on the fourth several inches before collapsed gut began. The post-operative day. mesentery was present opposite the undeveloped Post-mortem examination (Fig..i i) showed com- segment but was very thin. The proximal loop plete absence of a segment of the upper jejunum, was emptied by putting a catheter into it and a the proximal bowel being grossly distended. The author wishes to thank the physicians of the Westminster Children's Hos?ital fot permission to publish cases referred .by them, and Mr. Albert Davis for his kindness in obtaining X-rays showting gas shadows in the intestines of newborn infants.

* ANAESTHETIC EMFRGENCIES BY J. ALFRED LEE, M.R.C.S., L.R.C.P., M.M.S.A., D.A., F.F.A., R.C.S. Consultant Anaesthetist to The General Hospital, Southend; The General Hospital; Rochford; King George Hospital, Ilford, etc.

Emergencies are always hiding round the If minor degrees of obstruction of the upperby copyright. corner, waiting to pounce on the anaesthetized respiratory tract also exist in these patients, they patient, and it is axiomatic that throughout the may soon become quite seriously hypoxic, and if whole of the administration the anaesthetist should they are in add;tion physically handicapped, a be intelligently alert. The price of safety is state of emergency may soon develop. constant watchfulness-in somno securitas. The remedy here is partly preventive and partly Anaesthetic emergencies cannot always be curative. The dosage of powerful drugs should be treated successfully, and it is a melancholy re- ' tailor made' to suit the type and constitution of flection that deaths under anaesthesia are not each individual patient. It should be remembered

decreasing. When calculated on a quarter of a that old people, those suffering from chronic de- http://pmj.bmj.com/ million cases from five teaching hospitals in three bilitating disease, those ofhypothyroid.constitution countries, the death rate was about one in a and those already receiving sedative drugs, will thousand (Gillespie, ). The operating theatre probably require less opiate or barbiturate than is no place for a display of virtuosity, and it is the average patient. The modem treatment of always wiser to use an agent or method with Graves' disease may produce in the thyrotoxic Which one is familiar than to employ a technique patient a temporary hypothyroidism which will with which one is not au fait, just because it may make it difficult for him to deal with doses of be theoretically indicated. bromethol normally suitable for such patients on September 25, 2021 by guest. Protected Crises can arise in the anaesthetic room, in the before operation. When these depressed patients operating theatre or during the immediate' post- are transferred to the care of the anaesthetist, their operative period. condition should improve. He is able to ad- minister mixtures rich in oxygen, secure a good Anaesthetic Room Emergencies airway and make a smooth induction. He should, It will occasionally happen that a patient arrives however, bear in mind that if he uses more for operation in a state of depression consequent respiratory depressants during anaesthesia he must on the ill-judged dosage of sedative premedication. be prepared to assist the normal respiratory effort The writer has known operations postponed for of the patient. this reason. Now and again opium derivatives Scopolamine hydrobromide is a useful drug for seem to exert an overwhelming effect even if the two reasons; it reduces secretions from the upper dosage is appropriate, and the patient may be respiratory tract and it produces amnesia. It breathing no more than six or eight times a minute. should not be used as a routine, however, in Bromethol, likewise a respiratory depressant, may patients over 6o years of age, because occasionally seriously reduce the rate and depth of breathing. a state of restlessness or even delirium may