- Email: [email protected]
A NEW OPERATION FOR HÆMORRHOIDS.
A DISCUSSION
ON
possess a short option for the purchase of a very desirable site for the proposed additions. It would be most regrettable if the money was not forthcoming until the site had been otherwise disposed of. A
DISCUSSION
ON
THE CRUET.
THE abolition of the cruet has been solemnly discussed. First salt is banned on the ground that it delays digestion or has an unfavourable action akin to a mild poison and can further act as an emetic ; next pepper is convicted of an irritant effect on the gastric organs, as well as upon the organs of secretion, and, besides, contains an alkaloid ; then vinegar may precipitate an attack of gout, while its use to produce a colourless complexion is quoted as evidence of its injurious effects ; mustard, like pepper, is an irritant also and its effects as a blister are not forgotten, in addition to which it is a well-known emetic; lastly, olive oil is indigestible, coating food with oil and so preventing the gastric juices from doing their beneficent work. On the face of it we have here a series of serious indictments which might tempt some to regard the very old institution of the cruet as after all a great human error. The acceptance of such a view betrays little knowledge. Each item of the cruet is of decided service in dietetics, and we have something more than the argument that the use of condiments is merely instinctive to support this statement. The classic experiments of Pawlow have shown how important is the r6le of the condiments in diet, how it is they improve appetite and increase digestive Mustard, pepper, and salt, used, of course, in power. sensible amounts, assist the appetite, give a zest for food, and partly by reflex action as well as local action, stimulate the flow of digestive juices and ensure healthy assimilation. Even vinegar is known to have a softening effect on tough fibres, and hence its use is justified in so many instances. Lastly, the use of oil in a salad is a sound physiological procedure, for it supplies an aliment which is deficient in the salad vegetable, while as a vehicle for the uniform distribution of food materials in the human organism it does The reasons for the existence of the excellent service. cruet and of its continued use are, therefore, by no means merely empirical, the institution is physiologically justified.
519
THE CRUET.
crushed pedicle is then covered in by drawing together the surrounding mucous membrane by means of a pursestring suture. The operation is a modification of the removal of haemorrhoids by excision, the real difference being that the vessels of the haemorrhoids are crushed instead of being tied. It does not appear that Mr. Norman Porritt has performed the operation in many cases, but we have no doubt that it is capable of producing satisfactory results. In all these operations, as in many others, the man who performs the operation is much more important than the method he happens to use. We should like to hear further on the subject when there is the necessary material, for the number of sufferers is very great. -
VAGINAL SUTURE IN RUPTURE OF THE UTERUS. THE best method of dealing with a case of rupture of the uterus is always a most difficult question for the practitioner to decide. In many cases the question is decided for him, since the patient is not in a condition to stand operative interference and her rapid death renders treatment of any kind impossible. At the same time a certain number of
these cases recover without any treatment, and it would be easy to quote figures from the monographs written on the subject to prove the apparent efficacy of the different procedures adopted. Undoubtedly the ideal treatment, if the is in a condition to stand it, is the removal of the patient child and placenta by abdominal section whenever they have passed into the peritoneal cavity, and the subsequent removal of the uterus by complete hysterectomy. In this way perfect control of the hæmorrhage and free drainage through the vagina can be secured, and this method has the further great advantage that a source of possible septic trouble in the damaged uterus is removed. The high mortality following this operation, however, has led many surgeons to recommend less severe measures. Of these the one most frequently adopted and the most successful is the plan of plugging the tear with gauze, and so arresting the hæmorrhage and providing for drainage. It is a noteworthy fact that in most of the cases the haemorrhage, although no doubt severe at the time, soon ceases spontaneously, and if the patient survives the immediate dangers of the accident she does not, as a rule, die from further haemorrhage. Gauze plugging therefore probably acts rather as a drain than as a hæmostatic, and this A NEW OPERATION FOR HÆMORRHOIDS. may be the explanation of the good results obtained in these MANY are the operations which have been devised for the cases and the answer to the objection that any firm plugging adical cure of haemorrhoids, and the enthusiasm with which of the tear is virtually impossible, since there is no each in turn is praised by one surgeon is only equalled by the means of making counter pressure, at any rate in comopposition which it meets with from other operators. For plete tears. Naturally enough, when the tear has been instance, Whitehead’s operation has been, and is still, readily accessible surgeons have made attempts to treat it regarded by some as the very perfection of methods for the by suture as well as by plugging. Cases of this kind are to thorough removal of the hæmorrhoidal tissue, but others look be found in the literature and an interesting example is the upon it as needlessly mutilating and extremely liable to one described by Mr. H. J. Paterson in this issue of produce stricture. Similar opinions have been expressed in THE LANCET. In his case the cervix and lower uterine regard to ligature and to the clamp and cautery. The fact is segment were torn through for a distance of four inches, and that with any one of these methods a surgeon practised in its there was as well a tear in the posterior vaginal fornix, use can obtain excellent results, and the failures occur almost through which a portion of the sigmoid flexure prolapsed into entirely in the hands of those who have had but little expe- the vagina. The tear extended into the left parametrium, rience of the method. Success in most cases depends on but was complete. The tear in the uterus was sewn up sucattention to small points which are often not described in I, cessfully with catgut sutures and the opening in the vaginal text-books, and are therefore liable to be neglected by those I vault closed with a purse-string suture round a rubber who have not practised the special method to any drainage-tube ; two large vessels which were bleeding were extent. In a recent issue of THE LANCET appears an account controlled by ligatures. Continuous proctolysis was carried out by Mr. Norman Porritt of Huddersfield of a new operation for 60 hours after the operation, and the patient made a good which he has devised and employed successfully for recovery. Mr. Paterson thinks that the advocates of hysterecthe radical cure of haemorrhoids. It consists essentially tomy lay too much stress upon the difficulty of controlling in the crushing of the base of the pile with a pair haemorrhage, but in this he hardly does them justice. A conof crushing forceps, such as those devised by Kocher number of writers on this subject have pointed out the and modified by Corner for appendix. The that after the first severe bleeding there is often but little more,
great
siderable
ON
possess a short option for the purchase of a very desirable site for the proposed additions. It would be most regrettable if the money was not forthcoming until the site had been otherwise disposed of. A
DISCUSSION
ON
THE CRUET.
THE abolition of the cruet has been solemnly discussed. First salt is banned on the ground that it delays digestion or has an unfavourable action akin to a mild poison and can further act as an emetic ; next pepper is convicted of an irritant effect on the gastric organs, as well as upon the organs of secretion, and, besides, contains an alkaloid ; then vinegar may precipitate an attack of gout, while its use to produce a colourless complexion is quoted as evidence of its injurious effects ; mustard, like pepper, is an irritant also and its effects as a blister are not forgotten, in addition to which it is a well-known emetic; lastly, olive oil is indigestible, coating food with oil and so preventing the gastric juices from doing their beneficent work. On the face of it we have here a series of serious indictments which might tempt some to regard the very old institution of the cruet as after all a great human error. The acceptance of such a view betrays little knowledge. Each item of the cruet is of decided service in dietetics, and we have something more than the argument that the use of condiments is merely instinctive to support this statement. The classic experiments of Pawlow have shown how important is the r6le of the condiments in diet, how it is they improve appetite and increase digestive Mustard, pepper, and salt, used, of course, in power. sensible amounts, assist the appetite, give a zest for food, and partly by reflex action as well as local action, stimulate the flow of digestive juices and ensure healthy assimilation. Even vinegar is known to have a softening effect on tough fibres, and hence its use is justified in so many instances. Lastly, the use of oil in a salad is a sound physiological procedure, for it supplies an aliment which is deficient in the salad vegetable, while as a vehicle for the uniform distribution of food materials in the human organism it does The reasons for the existence of the excellent service. cruet and of its continued use are, therefore, by no means merely empirical, the institution is physiologically justified.
519
THE CRUET.
crushed pedicle is then covered in by drawing together the surrounding mucous membrane by means of a pursestring suture. The operation is a modification of the removal of haemorrhoids by excision, the real difference being that the vessels of the haemorrhoids are crushed instead of being tied. It does not appear that Mr. Norman Porritt has performed the operation in many cases, but we have no doubt that it is capable of producing satisfactory results. In all these operations, as in many others, the man who performs the operation is much more important than the method he happens to use. We should like to hear further on the subject when there is the necessary material, for the number of sufferers is very great. -
VAGINAL SUTURE IN RUPTURE OF THE UTERUS. THE best method of dealing with a case of rupture of the uterus is always a most difficult question for the practitioner to decide. In many cases the question is decided for him, since the patient is not in a condition to stand operative interference and her rapid death renders treatment of any kind impossible. At the same time a certain number of
these cases recover without any treatment, and it would be easy to quote figures from the monographs written on the subject to prove the apparent efficacy of the different procedures adopted. Undoubtedly the ideal treatment, if the is in a condition to stand it, is the removal of the patient child and placenta by abdominal section whenever they have passed into the peritoneal cavity, and the subsequent removal of the uterus by complete hysterectomy. In this way perfect control of the hæmorrhage and free drainage through the vagina can be secured, and this method has the further great advantage that a source of possible septic trouble in the damaged uterus is removed. The high mortality following this operation, however, has led many surgeons to recommend less severe measures. Of these the one most frequently adopted and the most successful is the plan of plugging the tear with gauze, and so arresting the hæmorrhage and providing for drainage. It is a noteworthy fact that in most of the cases the haemorrhage, although no doubt severe at the time, soon ceases spontaneously, and if the patient survives the immediate dangers of the accident she does not, as a rule, die from further haemorrhage. Gauze plugging therefore probably acts rather as a drain than as a hæmostatic, and this A NEW OPERATION FOR HÆMORRHOIDS. may be the explanation of the good results obtained in these MANY are the operations which have been devised for the cases and the answer to the objection that any firm plugging adical cure of haemorrhoids, and the enthusiasm with which of the tear is virtually impossible, since there is no each in turn is praised by one surgeon is only equalled by the means of making counter pressure, at any rate in comopposition which it meets with from other operators. For plete tears. Naturally enough, when the tear has been instance, Whitehead’s operation has been, and is still, readily accessible surgeons have made attempts to treat it regarded by some as the very perfection of methods for the by suture as well as by plugging. Cases of this kind are to thorough removal of the hæmorrhoidal tissue, but others look be found in the literature and an interesting example is the upon it as needlessly mutilating and extremely liable to one described by Mr. H. J. Paterson in this issue of produce stricture. Similar opinions have been expressed in THE LANCET. In his case the cervix and lower uterine regard to ligature and to the clamp and cautery. The fact is segment were torn through for a distance of four inches, and that with any one of these methods a surgeon practised in its there was as well a tear in the posterior vaginal fornix, use can obtain excellent results, and the failures occur almost through which a portion of the sigmoid flexure prolapsed into entirely in the hands of those who have had but little expe- the vagina. The tear extended into the left parametrium, rience of the method. Success in most cases depends on but was complete. The tear in the uterus was sewn up sucattention to small points which are often not described in I, cessfully with catgut sutures and the opening in the vaginal text-books, and are therefore liable to be neglected by those I vault closed with a purse-string suture round a rubber who have not practised the special method to any drainage-tube ; two large vessels which were bleeding were extent. In a recent issue of THE LANCET appears an account controlled by ligatures. Continuous proctolysis was carried out by Mr. Norman Porritt of Huddersfield of a new operation for 60 hours after the operation, and the patient made a good which he has devised and employed successfully for recovery. Mr. Paterson thinks that the advocates of hysterecthe radical cure of haemorrhoids. It consists essentially tomy lay too much stress upon the difficulty of controlling in the crushing of the base of the pile with a pair haemorrhage, but in this he hardly does them justice. A conof crushing forceps, such as those devised by Kocher number of writers on this subject have pointed out the and modified by Corner for appendix. The that after the first severe bleeding there is often but little more,
great
siderable