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CHEMICALSTUDIES OF THE BLOODIN HIGHINTESTINAL OBSTRUCTION

II. THE RELATION BETWEEN"TOXEMIAAND CHEMICAL CHANGES

By WILLIAM DEWITTANDRUS,GEORGEM. GUEST, RICHARDF. GATES,AND ALTA ASHLEY

(From the Children's Hospital Research Foundation and the Departments of Surgeryand of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati)

(Received for publication October 22, 1931)

In the preceding paper (Guest and Andrus, 1932) certain of theprincipal changes occurring in the blood of dogs following simple py-loric or mid-duodenal obstruction have been discussed. Experimentswere reported in which the distribution of phosphorus in the blood ofdogs with obstruction was determined, and changes in various fractionsof the blood phosphorus were correlated with other chemical changesof the blood which are generally known to be associated with intes-tinal obstruction. The greatest change in the blood phosphorus wasin that fraction designated as the "organic acid-soluble ester-P" practi-cally all of which is contained in the cells. Changes in the chloridecontent of both plasma and cells were compared with concomitantchanges in the distribution of phosphorus, and a close correlation be-tween the progressive losses of chloride from the blood cells and theincreases of the ester-P of the cells was demonstrated. From thesefindings it was concluded that in the acid-base equilibrium of the cellsthese organic phosphorus compounds had some sort of a reciprocalrelationship to the cell chloride, and that as these phosphorus com-pounds increased they were bound to the alkali in the cells from whichchloride was lost, much as HCO3' is known to be retained by the alkaliof the blood from which Cl' is lost. In those experiments it was alsoshown that the parenteral administration of NaCl solution preventedincreases of ester-P in the cells to about the same degree that it pre-vented losses of chloride.

The two theories most commonly accepted in explanation of thecause of death in intestinal obstruction are: (1) that death is due todehydration and disturbance of the acid-base equilibrium of the bodywhich follows the loss of electrolytes and water by vomiting and byfailure of reabsorption of gastro-intestinal secretions from the obstructedbowel; (2) that death is due to a state of intoxication of the tissuesbrought about by toxic substances absorbed from the obstructed bowel.

475

INTESTINAL OBSTRUCTION: TOXEMIA

The efficacy of the administration of NaCl solution in prolonging thelife of animals with simple experimental high obstruction is one of thestrongest indications that in this condition the loss of water and elec-trolytes is the principal lethal factor; on the other hand, with "closedloops" or in obstruction with strangulation such treatment is less effi-cacious and in these circumstances the factor of toxemia appears tohave greater importance.

Clinically, one seldom encounters circumstances capable of pro-ducing the picture of simple obstruction as it is experimentally producedin animals, because constrictions and other factors introduce the com-plications of strangulation in a high percentage of cases. With strangu-lation of the intestine, death occurs much more quickly than in simpleobstruction, and much work has been done to demonstrate that in suchcases the greater severity of symptoms is due to toxic substances whichappear in the obstructed bowel. Filtrates and certain extracts of thebowel contents from above the point of obstruction are extremelytoxic when injected into animals, and many attempts have been madeto isolate and identify the substance, or substances, responsible forthis toxicity. A review of this work may be found in the article byCooper (1928). Whipple and his collaborators (1916) believed thetoxic substances to be of proteose nature, while Gerard (1922) andothers have pointed out the similarity in the pharmacologic effectsof these extracts and of histamine. Most of the evidence accumulatedfrom many different studies indicates that the toxic agent is some prod-uct of protein degradation, probably several related substances, andthat many of the properties and effects of these substances are likethose of histamine. Apparently the toxic substance is not absorbedby the normal mucosa (Davis (1914), Murphy and Brooks (1915))but it has been demonstrated that the mucosa of the bowel above thepoint of obstruction is not normal, that increased tension within thebowel may cause absorption to take place (Stone and Firor (1924))and that breaks in the continuity of the mucosa may be produced (Mur-phy and Brooks (1915), Van Buren (1920)) which allow the toxic sub-stance to enter the tissues.

The presence of toxic substances in the obstructed bowel cannot bedenied, but there has been much controversy over their importancein causing death, compared to the importance of the losses of electrolytesand the accompanying chemical changes of the body fluids. Thestudies to be reported here were undertaken with the idea that thesetwo theories of the cause of death in intestinal obstruction could bebetter correlated, and that the chemical changes and the "toxemia"9could be demonstrated to be interdependent. Dragstedt (1928) hasalready postulated such a relationship, as follows: "the toxic fractionsin obstruction fluids are powerful secretogogues, and when injected

476

W. D. ANDRUS, G. M. GUEST, R. F. GATES AND A. ASHLEY 477

into dogs cause a marked augmentation of gastric, pancreatic and intes-tinal secretion. Accordingly it seems probable from this as well asother evidence obtained by other workers, that the fall in blood chloridesin obstruction is due to their accelerated passage into the alimentarytract and failure of reabsorption."

In the experiments here described, histamine is employed as a knownsubstance which is at least closely related to the toxic substances pres-ent in and absorbable from the obstructed bowel. Injected sub-cutaneously, histamine stimulates a rapid flow of gastric juice of highHCl content. In normal animals such injections cause only slightlowering of the blood chlorides, even when given at frequent intervalsand continued over a long period (Lim and Ni (1926), Drake and Tisdall(1926)); presumably this is because most of the secreted gastric juiceis reabsorbed after passing through the pylorus. However, if the flowof gastric juice thus stimulated is allowed to escape, the repeated in-jections of histamine are rapidly followed by marked blood chemicalchanges and death. Lim and Ni reported experiments in which dogswith Pavlov pouches were subjected to hourly subcutaneous injectionsof histamine in doses of 0.2 mgm. per kilogram body weight. Onesuch dog (G. 17), given increasing doses of histamine, averaging 1.9mgm. per hour, succumbed at the end of 10 hours; during this timethe chloride of the whole blood fell from 308 mgm. per 100 cc. (87 mM.)before the injections to 222 mgm. per 100 cc. (62.7 mM.) at the 10thhour. "Gastric secretion was obtained up till the last, the total se-creted being 743 cc. of juice and 3190 mgm. of Cl . . . in spite of thedehydration and large amount of Cl lost, amounting in one animal to 49per 100 cc. of the total body Cl, the gastric glands continue to secrete."Similar results were obtained when unoperated animals were injectedwith repeated doses of histamine while the gastric secretions were con-tinuously aspirated by means of a Rehfuss tube. A gastrectomizeddog, on the other hand, showed no fall in the blood Cl after histamineinjections. Two points may be considered established by such experi-ments as these: first, that the secretion of HCl with the gastric juiceis the fundamental cause of the fall of the blood chloride when thesesecretions are lost from the body; secondly, that histamine will markedlyaccelerate such losses.

Certain objections may here be made to some of the conclusionsdrawn from previous experimental studies of this problem in whichvarious preparations of filtrates or toxic substances isolated from thecontents of the obstructed bowel were injected intravenously to provetheir toxicity in normal animals. Such an injection may provokethose symptoms generally known as "shock," and immediate death,but clinically one rarely sees such fulminant progress of symptomsleading to death. Histamine when injected intravenously immedi-


ately provokes a train of severe symptoms, whereas subcutaneousinjections have less severe effects which may be considered more physi-ologic in nature. The slow absorption of the toxic substances from thebowel, when this does occur, must have effects more nearly like thoseof subcutaneous injections than like those of a large overwhelmingdose suddenly injected intravenously. Moreover, the injection of alarge dose of toxic substance, either intravenously or subcutaneously,may be followed by a severe reaction which is not necessarily simplyan exaggeration of the effect of a small dose. If one is to reproduce theconditions that are encountered clinically, it would seem that the re-peated subcutaneous injections of very small doses of these toxic sub-stances, at short intervals, should more nearly duplicate the conditionsimposed by their gradual absorption into the tissues from the obstructedbowel; this method was, therefore, employed in the experiments thatfollow.

EXPERIMENTAL

Methods: The methods used in the experiments were the same asthose described in the preceding paper.

Pyloric obstruction. Dog number 266. (Table 1)In this table are given figures which illustrate the typical changes

observed in the blood of a dog with simple pyloric obstruction. Theprincipal changes demonstrated in this experiment are: (1) The rela-tive cell volume increased in the second blood sample but decreasedagain in the third sample. The erythrocyte size was unchanged inthe last sample, but ordinarily there is observed a slight diminutionin this value. (2) The hemoglobin content of the cells remained practi-cally unchanged, demonstrating that in this important constituent thered cells remained normal. (3) The serum protein and the nonproteinnitrogen increased. (4) The chloride fell markedly in both plasmaand cells. (5) The CO2 content of both plasma and cells increasedin the second sample, but fell terminally, presumably because of theincrease of organic acids which is to be expected at this time. (7)There was a marked increase of the organic acid-soluble ester-P of thecells, evident in the figure for this fraction in the packed cells (84.5mgm. per 100 cc.) and in the ratio of Ester-P: RBCcount. The nextgreatest change of the blood phosphorus was in the inorganic fractionin the plasma.

Pyloric fistula + histamine. Dog number 262. (Table 2)In this dog, under ether anesthesia, the pylorus was severed, the

distal stump inverted and sutured and a pyloric fistula created throughthe abdominal wall. With a soft rubber tube in the fistula opening,the dog was kept in a frame for the collection of the gastric secretions.

478


TABLE 1

Dog number 266. Pyloric obstruction. AlUowed water ad lib., starting 18 hours afteroperatson. Lived 71 hours

Hours after operationNormal

48 70

Weight ........ .............. kgm. 23.2 21.2 20.1Blood cells, total ................ volumes per cent 51.5 56.4 50.8

RBC, only ................. volumes per cent 50.1 53.6 48.9RBC.................... millions per c.mm. 7.91 7.75

Erythrocyte size ...................... cu. mu 63.3 63.1Hemoglobin whole blood ...... . grams per 100 cc. 17.19 17.12Hemoglobin cells .............. grams per 100 cc. 34.3 35.0Hb: RBCcount ratio . .............. 2.17 2.21Serum protein ................grams per 100 cc. 9.2 10.6 11.0Nonprotein nitrogen .......... . mgm. per 100 cc. 30* 100 169Sugar ....................... mgm. per 100 cc. 91 163 35.3C02 content, plasma ............... mM. per liter 22.0* 32.76 27.44CO2content, cells.mM. per liter 13.0* 18.84 14.25Chloride, plasma ................... mM. per liter 106.0* 78.5 73.5Chloride, cells ..................... mM. per liter 58.0* 36.8 28.2

Phosphorus distribution

Whole blood1. Inorganic ................... mgm. per 100 cc. 3.2 5.26 8.772. Total acid-soluble ............ mgm. per 100 cc. 29.4 42.2 52.23. Organic "Ester-P" ............. mgm. per 100 cc. 26.2 36.94 43.434. TOTAL...................... mgm. per 100 cc. 49.1 69.0 76.25. Acid-insoluble ............... mgm. per 100 cc. 19.7 26.8 24.0Ester-P: RBCcount ratio. ....... . 3.31 4.35t 5.6

Plasma1. Inorganic .............. mgm. per 100 cc. 3.8 7.47 13.82. Total acid-soluble ............ mgm. per 100 cc. 4.2 8.16 14.83. Organic " Ester-P ............. mgm. per 100 cc. 0.4 0.7 1.04. TOTAL.............. mgm. per 100 cc. 21.6 29.7 34.45. Acid-insoluble .............. mgm. per 100 cc. 17.4 21.5 19.6

Cells1. Inorganic .............. mgm. per 100 cc. 2.63 3.55 3.902. Total acid-soluble ............ mgm. per 100 cc. 53.1 68.5 88.43. Organic "Ester-P ............. mgm. per 100 cc. 50.5 65.0 84.54. TOTAL.............. mgm. per 100 cc. 75.0 99.4 116.7S. Acid-insoluble .............. mgm. per 100 cc. 21.9 30.9 28.3

* Assumed normal values, taken for comparison.t The RBC count was lost in this second sample. Assuming that the

erythrocyte size did not change, the RBCcount in the second sample would be8.48 millions per c.mm. The value 4.35 for the ester-P ratio is interpolatedfrom this figure.


After apparent recovery from the anesthesia, 3 hours after operation,1 mgm. doses of histamine in 1 cc. of 0.9 per cent NaCl solution were

injected subcutaneously at half-hourly and hourly intervals. Theseinjections were continued until the dog died at the end of 16 hours(19 hours after the operation) by which time a total of 20 mgm. ofhistamine had been injected. During the first 12 hours of the injectionsthe flow of gastric juice was almost continuous, observed as a smallthin mucoid stream which was visibly accelerated by each injection ofhistamine. After 12 hours, the flow diminished considerably, and theresponse to each injection of histamine was much less. The totalgastric secretions collected contained the equivalent of 1050 cc. ofN/10 HCI. Complete analyses on the preliminary small blood sample

TABLE 2

Dog number 262. Pyloric fistula + histamine. Died 16 hours aftersubcutaneous injections of 1 mgm. histamine

start of hourly

Normal After histamineinjections

Blood cells, total .............. volumes per cent 47.8 45.2RBC, only .............. volumes per cent 46.3 43.6RBC............... millions per c.mm. 6.60 6.58

Erythrocyte size .............. cu. mu 70.1 66.2Serum protein .............. grams per 100 cc. 7.0 10.8Nonprotein nitrogen .............. mgm. per 100 cc. 25 64Sugar .............. mgm. per 100 cc. 90 50CO2 content, plasma .............. mM. per liter 22 38.5Chloride, plasma .............. mM. per liter 108.5 89


Whole blood1. Inorganic . ............. mgm. per 100 cc. 2.38 4.762. Total acid-soluble... mgm. per 100 cc. 27.2 37.73. Organic "Ester-P .............. mgm. per 100 cc. 24.82 32.944. TOTAL............... mgm. per 100 cc. 42.5 59.35. Acid-insoluble .............. mgm. per 100 cc. 15.3 21.6Ester-P: RBCcount ratio . . ......... 3.75 5.00

Plasma1. Inorganic .............. mgm. per 100 cc. 2.72 6.92. Total acid-soluble .............. mgm. per 100 cc. 3.33 7.253. Organic " Ester-P .mgm. per 100 cc. 0.6 0.354. TOTAL.............. mgm. per 100 cc. 12.4 25.55. Acid-insoluble .............. mgm. per 100 cc. 9.07 18.25

Cells1. Inorganic .............. mgm. per 100 cc. 2.01 2.172. Total acid-soluble .............. mgm. per 100 cc. 53.2 74.63. Organic "Ester-P .mgm. per 100 cc. 51.2 72.44. TOTAL.............. mgm. per 100 cc. 75.4 100.35. Acid-insoluble .............. mgm. per 100 cc. 22.1 25.7

480


taken before operation were not made; in the first column of Table 2are listed for comparison the figures for nonprotein nitrogen, CO2content, Cl and phosphorus distribution determined in the blood of anormal dog which had approximately the same relative cell volume,cell count, and hemoglobin. In the blood sample taken just beforedeath (second column, Table 2) note especially the following values: (1)elevated serum protein and nonprotein nitrogen; (2) the low Cl and highCO2 content of the plasma; (3) the increased phosphorus content of thecells, the increase being practically all in the ester-P fraction. In thislast blood sample were found values of such magnitude of change fromthe normal as have been observed in the blood of dogs with simple pyloricobstruction (i.e., without histamine injections, or other treatment) onlyat 48 to 72 hours or longer after operation; in this dog these changes devel-oped in the brief course of 19 hours after operation, or only 16 hours afterthe histamine injections were started.

Normal dog injected with histamine; followed by pyloric obstruction andrepeated histamine injections. Dog number 272. (Table 3)

A normal dog was subjected to hourly subcutaneous injections of 1mgm. of histamine, in 1.0 cc. of 0.9 per cent NaCl solution, for 48 hours.Food was withheld. Throughout this period the animal manifested nooutward signs of ill effects of the injections at any time. Blood sampleswere taken for analysis before the injections were started and again at24 and 48 hours. After 16 days of rest a pyloric obstruction was createdand immediately after recovery from the ether anesthesia the dog wassubjected to the same hourly subcutaneous injections of histamine asbefore. Blood samples were again taken at the intervals indicated in thetable. Since it was undesirable to draw large blood samples, completeanalyses were not done on the preliminary blood samples taken beforeeach of these experiments. The injections of histamine in the unoperatedanimal were almost without significant effect on the blood. There was aslight but measurable diminution in size of the erythrocytes, 65.5 to62.4 cu. microns, and a slight diminution of the chloride, more noticeablein the cells. The ester-P of the cells increased slightly. After pyloricobstruction, 16 days later, the same injections of histamine were attendedby rapid changes in the blood, as follows: (1) Concentration of the blood,indicated by the increasing red blood cell count and increased serumprotein. (2) Loss of chloride and increase of CO2 in both plasma andcells. (3) Increases of the total phosphorus, practically all in the ester-Pfraction in the cells. These changes were in no wise different from thoseobserved in other dogs with simple pyloric obstruction, but developedmuch more rapidly. In the last blood sample, taken 1 hour before death(22 hours after operation) after 16 injections of 1 mgm. doses of histamine,the magnitude of changes in the blood is, as in the previous experiment,

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approximately that seen in dogs with simple pyloric obstruction at 48 to72 hours, or longer, after operation.

Pyloric obstruction + salt solution + histamine. Dog number 297.(Tables 4 and 5)

In dogs with simple pyloric obstruction the parenteral administrationof NaCl solution in appropriate amounts (around 50 cc. or more per kilo)prolongs life in the animals and diminishes the alterations of the blood,

TABLE 4

Time schedule of the experiment shown in Table 5 for dog number 297

Hours after 0.9 per cent Number ofoperation NaCl solution blood sample Notes

cc.1 Weight before operation, 21 kgm. Sample

taken 24 hours before operation.

150022.100030 2 Histamine 1 mgm. in 1 cc. 0.9 per cent NaCl36. 1350 solution; hourly injections started immediately48.1000 after 2nd blood sample was taken, and con-52 3 tinued through 48 hours.54.150060.120072. 100078 4

as described in the first paragraph of this paper. If the effect of histaminein hastening death in obstructed dogs is mainly one of stimulating gastricsecretion and thus accelerating the losses of chloride from the body, thenthe administration of salt solution in sufficient amounts theoreticallyshould protect these dogs as well as those with simple obstruction. Thefollowing experiment was performed to determine whether such protec-tion could be obtained.

In a dog weighing 21 kgm. the pylorus was obstructed, under etheranesthesia, with the usual technic. Immediately after operation 1500 cc.of salt solution were given subcutaneously. Again at 22 hours after op-eration 1000 cc. of salt solution were given. At 30 hours after operation ablood sample was taken and immediately afterwards hourly subcutaneousinjections of 1 mgm. histamine in 1.0 cc. 0.9 per cent NaCl solution werestarted. (This interval of 30 hours before starting the histamine injec-tions was allowed so that the dog might recover from the immediateeffects of the anesthesia and operation. A repetition of this experiment,in which both the histamine injections and the parenteral administrationof salt solution were started immediately after operation, gave almostexactly the same results as shown here, so this time interval appeared to

484


TABLE 5

Dog number 297. Pyloric obstruction + salt solution;for 48 hours

hourly injections of histamine

Hours after operation .............................. Before 30 52 78Number of blood sample ........................... 1 2 3 4

Blood cells, total ......... . volumes per cent 44.2 49.9 48.4 40.9RBC, only ........... .. volumes per cent 43.1 48.3 46.8 39.6RBC................ millions per c.mm. 6.45 8.20 8.50 6.45

Erythrocyte size .................. cu. mu 66.8 58.9 55.0 61.4Hemoglobin whole blood.... grams per 100 cc. 15.76 15.44Hemoglobin cells .......... grams per 100 cc. 36.5 39.0Hb: RBCcount ratio . ............. 2.44 2.39Serum protein ............. grams per 100 cc. 7.8 10.4 8.72 7.44Nonprotein nitrogen ...... . mgm. per 100 cc. 30* 20 25Sugar .............. mgm. per 100 cc. 90* 85 59C02 content, plasma ........ . mM. per liter 22.0* 32.1 32.8CO2content, cells ............. mM. per liter 13.0* 17.4 18.4Chloride plasma .............. mM. per liter 111.0 111.5 113.0 114.5Chloride cells .............. mM. per liter 60.1 53.4 40.7 59.5


Whole blood1. Inorganic ............ . mgm. per 100 cc. 3.12 3.02 2.7 3.242. Total acid-soluble ..... . mgm. per 100 cc. 24.6 32.3 34.5 29.43. Organic "Ester-P" ..... . mgm. per 100 cc 20.5 29.3 31.8 26.164. TOTAL.............. mgm. per 100 cc. 40.0 48.7 51.5 45.05. Acid-insoluble .......... mgm. per 100 cc. 15.4 16.4 17.0 15.6Ester-P: RBCcount ratio . . ....... 3.18 3.57 3.74 4.05

Plasma1. Inorganic ............ . mgm. per 100 cc. 2.922. Total acid-soluble ..... . mgm. per 100 cc. 4.323. Organic "Ester-P" .m.... mgm. per 100 cc. 0.44. TOTAL................. mgm. per 100 cc. 14.6 17.1 17.4 15.05. Acid-insoluble .......... mgm. per 100 cc. 10.7

Cells1. Inorganic. ....mgm. per 100 cc. 2.262. Total acid-soluble ....mgm. per 100 cc. 65.63. Organic "Ester-P" .. . mgm. per 100 cc. 47.5t 58.7t 65.7t 63.44. ToTAL ................. mgm. per 100 cc. 72.0 80.4 87.8 88.35. Acid-insoluble .......... mgm. per 100 cc. 22.7

* Assumed normal values, taken for comparison.t Where the complete analyses of plasma were not made, the organic

ester-P of the cells was calculated without allowing for the slight amount ofester-P in the plasma. The error thus introduced is negligible.

be unimportant.) Salt solution was again given at 36 hours and 48hours, and another blood sample was taken at 52 hours after operation.(See the time schedule of the experiment in Table 4.) In this blood sam-ple No. 3 the cell chlorides were found to be low and in the next 24 hoursthe administration of salt solution was increased. (See Table 4.) In


the last blood sample, at 78 hours, the chlorides of both plasma and cellswere again at practically the initial level. The nonprotein nitrogen hadremained normal. The total phosphorus of the cells increased, and thefigure for the Ester-P : RBCcount ratio steadily increased, but these in-creases in the cell P are not nearly as great as those shown after simplepyloric obstruction in Table 1. The changes in the plasma phosphoruswere negligible.

The dog was sacrificed after the blood sample taken 78 hours afteroperation (48 hours of histamine injections). The experiment had beencontinued long enough to demonstrate that the dog could be kept aliveby the parenteral administration of salt solution well beyond the time atwhich death occurred in dogs with obstruction, similarly injected withhistamine but not receiving salt solution. Were it not for the exigenciesof the experiment-the large blood samples that had been taken, etc.-it seems likely that this dog could have been kept alive for even a longertime by this treatment.

DISCUSSION

In these experiments it is demonstrated that when dogs with pyloricfistula or pyloric obstruction are injected with small repeated doses ofhistamine, they develop more rapidly all the chemical changes of the bloodwhich are ordinarily associated with intestinal obstruction, and die muchmore quickly than do the untreated dogs with simple obstruction. Innormal unoperated dogs similar injections of histamine continued for evenlonger periods were without visible deleterious effects and caused onlyslight changes in the blood. Histamine thus injected is known to have apowerful effect in stimulating the secretion of gastric juice. In normalanimals these secretions presumably pass through the pylorus into the in-testine to be reabsorbed and again form part of the body fluids. How-ever, in animals with obstruction and vomiting, such stimulation of thegastric secretion must accelerate the losses of gastric secretions from thestomach and therefore hasten the development of all the chemical changeswhich occur in the body in consequence of these losses. If one acceptsthe existing evidence that the alterations of the blood and body fluidsordinarily observed in simple high obstruction are due mainly to the lossesof water and electrolytes by vomiting, it seems reasonable to believe thatthe same mechanism is operative in producing the altogether similarchanges that are observed when dogs with obstruction are injected withhistamine. It seems unnecessary to postulate a general toxic action of thehistamine on the body tissues to explain the effects of histamine in hasten-ing death in the obstructed animals. The immediate death with thesymptoms of "shock" that follows the intravenous injections of largerdoses of histamine may be due to a different mechanism.

Work is in progress to determine whether or not the effects of sub-cutaneous injections of the toxic substances (proteoses or amines?)

486


from the contents of the obstructed or strangulated intestine, or fromclosed loops in dogs, are closely analogous to this effect of histamine.The absorption of such substances conceivably might be sufficiently rapidto cause immediate death with manifestations like those observed afterthe intravenous injection of these toxic substances, but in clinical ex-perience such a circumstance is certainly exceptional. It is likely thatthe slow absorption of these substances will be found to have an effectsimilar to that of histamine in stimulating the flow of gastric juice(Dragstedt and Dragstedt (1922)); if this be true, then it is possible thatthe most important effect of the slow absorption of toxic substances from astrangulated portion of bowel is not any general "intoxication" of thebody tissues, but an acceleration of all those secondary effects which ul-timately cause death.

In dogs with obstruction, injected with histamine, much more saltsolution was necessary to maintain the blood chlorides at a normal levelthan in similarly obstructed dogs not receiving histamine injections. InTable 4 it is to be noted that even though the plasma chloride remainedat a normal level in the obstructed dog receiving large amounts of saltsolution parenterally along with the hourly injections of histamine, thecell chloride fell markedly, from 60.1 mM. before operation to 53.4 and40.7 mM., in the blood samples taken at 30 and 52 hours, respectively,after operation. A larger amount of salt solution was given in the 24hours before the last blood sample was taken, 78 hours after operation,and in this blood the cell chloride was again at the normal level. Thisobservation of a fall in the chloride greater in the cells than in the plasmaafter histamine injections has been confirmed in several experiments, andwas observed by Lim and Ni (1926) in their experiments mentioned inthe early part of this paper. In several of the experiments with ob-structed dogs, both with and without histamine injections, it has seemedto be more difficult to prevent the losses of Cl from the blood cells andthe increases of ester-P in the cells than to maintain the plasma Cl at anormal level by means of the parenteral administration of NaCl solution.Much more work is needed to ascertain the significance of this in relationto treatment.

SUMMARY

In dogs with pyloric obstruction, repeated subcutaneous injections ofsmall doses of histamine have the effect of hastening the development ofthose chemical changes in the blood which have been claimed by many tobe the most important ultimate cause of death.

Histamine has been employed as a known substance which is at leastclosely related to the toxic substances which appear in the contents of asegment of obstructed or strangulated bowel. Histamine, injected sub-cutaneously as in these experiments, stimulates the flow of gastric juice

32


and in the presence of vomiting such increased secretion results in morerapid losses of electrolytes and water than occur in animals with simpleobstruction; in consequence of this there is a more rapid development ofthe whole cycle of the symptoms and chemical changes which ordinarilyaccompany intestinal obstruction.

From these experiments it is suggested that patients with intestinalobstruction plus strangulation, or dogs with experimental obstructionplus closed loops, die sooner than do those with simple obstruction notbecause of any specific general "intoxication" of the body tissues, butbecause the slow absorption of histamine-like substances from the bowelresults in an acceleration of the progress of all those chemical changeswhich occur secondarily to the losses of gastic secretions.

BIBLIOGRAPHY

Cooper, H. S. F., Arch. Surg., 1928, xvii, 918. The Cause of Death in HighObstruction.

Davis, D. M., Bull. Johns Hopkins Hosp., 1914, xxv, 33. Intestinal Obstruc-tion: Formation and Absorption of Toxin.

Dragstedt, L. R., Proc. Soc. Exp. Biol. and Med., 1928, xxv, 239. BloodChemistry in Intestinal Obstruction.

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