AN EMOTIONAL FAINT

1302

Fig. 6-Suture of gastric stump

The

gastric stump

to duodenal stump : AI. in fig. 5.

is now

81, and 82

ready for anastomosis,

as

the

stoma being held securely in the grip of the small clamp, and the terminal tooth transfixing both walls of the stomach, thus preventing any slipping out at the tips of the clamp. The conjoining clamps, and the technique described considerably simplify the preparation of a measured gastric stoma and a new lesser curve, an important step in modern subtotal gastrectomy which both facilitates anastomosis and improves function.

clamps replace the heavier more commonly used in

These light and slender andlarger instruments ’

gastrectomy. The clamps also assist in the anastomosis (particularly in the Billroth-I operation) by making the gastric and duodenal stumps easily controllable while the posterior seromuscular suture is being placed (fig. 6). Similarly, it is an additional advantage (in the Polya operation), although perhaps a small one, to have the selected segment of the jejunum -controlled by one of the small clamps (ng. 7). The antimesenteric’ margin of the jejunum can be neatly placed in the grip of one of the clamps by the method described ’by Paxinet (1945). In this way the jejunal opening can be measured to the gastric opening ; aligning for the postseromuscular suturing is facilitated ;

and the clamp tends to seal serosa and mucosa together, thus minimising pouting of the mucosa and oozing. By circumcising the seromuscular coats of the gastric stump just below the clamp (Maingot 1941) the vessels in the edge can, be identified and ligatured, thus producing a, bloodless anastomosis which is completed in the usual way. As regards closing the duodenal stump, the rail clamp is useful. The same technique is used which has been described for the first-row closure of the lesser curve. A single seromuscular suture is then placed in the middle of the stump, and the ends of this suture are clipped and held long. A three-point form of pursestring is placed round each corner. The suture in the middle is used as the fourth point of resistance for the burying of each corner. Two or three more interrupted sutures complete the closure. The -conjoining clamps give the same help in resections at the cardia of the stomach. The gastric opening is reduced to the size of the cesophageal opening, and the subsequent anastomosis is simplified by having the stomach and the oesophagus in the grip of the two small clamps. The conjoining clamps make an end-to-end ileotransverse colostomy after a right hemicolectomy a The technique used is most satisfactory operation. similar to.that described for preparation of the gastric stump, the lumen of the colon being reduced to the size of that of the small bowel. During the past three years I have used these instruments in both ttte Polya and the Billroth i forms of gastric resection. Polya has been used for most of the duodenal ulcers, and Billroth i for all gastric ulcers. The clamps have proved of considerable value in simplifying both forms of gastrectomy, and it is hoped that the instruments may contribute in a small way to the eventual standardisation of technique in partial

gastrectomy.

I wish to thank Mr. H. R. Thomson for much helpful criticism and advice. The clamps are made by T. H. Spicer & Son, 45, Marylebone High Street, London, W.I. REFERENCES

(1941) Technique of Gastric Operations. London. Maingot, Pannet, C. A. (1945) Brit. J. Surg. 32, 418. Stevenson, D. L. (1943) Brit. med. J. i, 13. R.

AN EMOTIONAL FAINT

DUNVILLE

A. D. M. GREENFIELD M.B., M.Sc. Lond. PROFESSOR OF PHYSIOLOGY, QUEEN’S UNIVERSITY,

BELFAST; FORMERLY SENIOR LECTURER IN EXPERIMENTAL PHYSIOLOGY, ST. MARY’S HOSPITAL MEDICAL SCHOOL, LONDON a student, aged 19, faiiited and fell while blood being withdrawn from another person’s arm’ vein. He had previously been healthy and has remained so. An attempt was made to cause him t6faint again in the same way while under close observation, so that the responses of an emotional faint could be compared with those of posthsemorrhagic fainting described by Barcroft et al. (1944) and Barcroft and Edholm (1945). The faint that resulted may not have been so purely of emotional origin as the first;’ but we have very little information about such faints, and there has since been no opportunity of making similar observa-. tions on another person. So the findings are presented here.

IN 1945

watching

’

,

.

’‘ METHODS A lead-11 electrocardiogram was recorded continuously with an ink-writing instrument. The Q R s complexes could be identified with certainty, but the record (fig. 1) was not good enough for, the mechanism of cardiac irregularities to be analysed. The arterial pressure was measured at intervals of a minute by auscultation. Unfortunately two readings were missed just before the z

,

Fig. 7-Control of segment operation : A[, Bt, and B2

jejunum with special clamp in Polya fig. 5. A small needle with margin of redundant Jejunum, is excised before clamp on jejunum is removed. of

as

in

1303 him to drink the few ml. of blood he had seen withdrawn from the other person’s arm. This stimulus was immediately effective, and a negligible amount of blood was swal-

lowed. The

subject

became

pale,

yawned, and said " I’m going." He lost consciousness, and would have fallen from the stool had he not been supported. The heart-rate slowed, only 37 beats being recorded in the first minute, and there were consecutive periods of II sec. and 7 sec. during which no Q R s complex was Fig. I-Lead II electrocardiogram at start of faint. detected (fia:. 1). The elecfaint and a third at its start. The forearm blood-flow trical record naturally shows a good deal of background was measured each minute by the venous-occlusion swing when the subject slumped forward, but careful the of Brodie principle inspection shows that it is most unlikely that a Q R s plethysmographic ’method, using and Russell (1905). The method was similar in detail complex is lost in this. The forearm blood-flow was maintained throughout the period of the faint at 4-5 ml. to that of Barcroft and Edholm (1945), and a pressure of 35 mm. Hg was used throughout in the collecting cuff so per 100 ml. per minute, well above the resting level. The first arterial pressure reading during the loss of consciousas to interfere as little as possible with the arterial inflow ness was 90/60 mm. Hg, but this was about 40 sec. after during the faint. It was impractical to have the subject standing up, the asystolic periods mentioned above. so he sat on a high stool with his legs and thighs as As soon as the essential observations had been made, from He was the as nearly, vertical possible. supported subject’s legs were raised to the horizontal position. behind while fainting. The room-temperature was 19-5°C. Consciousness was probably. lost for 1’ 12minutes. During its return one observer noticed some flushing of RESULTS the ears and face, which is a rather unusual finding. The The stimulus of seeing venepuncture done on another action of the heart was irregular, with coupled beats for person was less effective on the second- occasion than it several minutes, but this is not unusual (Lewis 1932). had been on the first. While preparations were being During recovery there was an episode of nausea and made, as obviously as possible, the student’s forearm retching accompanied by renewed slowing and irregularity blood-now (fig. 2) rose from a resting value of about 2.ml.. of the heart-beats for about 30 sec. This is not shown in to 7-5 ml. per 100 ml. per minute, his arterial pressure fig. 1. rose from 110/78 to 130/88 mm. Hg, and his heart-rate DISCUSSION increased. No further increases occurred when the Apart from the insertion of the needle into his arm, the blood was withdrawn. These are normal reponses stimuli applied to the subject were all emotional. The to an emotional stimulus insufficient to cause needle was sharp and caused little pain. If the time fainting. relation of the faint to the drinking of blood is taken into As the subject did not faint, a needle was now inserted account, it seems probable that this faint was mainly into his arm, but no blood was withdrawn. There was of emotional origin. again an increase in forearm blood-flow, but no faint. The changes observed in the circulation are similar It was therefore decided to increase the stimulus by asking to those in posthaemorrhagic fainting (Barcroft et al. 1944, Barcroft and Edholm 1945). The combination of increased - forearm blood-now ,and reduced arterial pressure is clear evidence of vasodilatation of the peripheral vessels in the forearm. In association with pallor of the skin, this almost certainly means that the vessels to the muscles were dilated. Dilatation of the vessels to the muscles in posthaemorrhagic fainting has been shown by Barcroft et al. to depend on sympathetic vasodilator fibres. Presumably the same is true of emotional fainting. Lewis (1932) has shown by the use of atropine that the slowing of the heart in similar faints is of vagal origin. ’

’

.

I

_

SUMMARY

Circulatory changes in an emotional faint are described : these were similar to those in posthaemorrhagio fainting. My thanks are due to Prof. A. St. G. Huggett, in whose department these observations were made ; Dr. D. McK. Kerslake and Mr. J. Hancock, who assisted with the observations ; and Mr. A. T. for fainting. REFERENCES

’Fig. 2-Circulatory changes during

emotional faint : A, watches preparations ;B, watches venepuncture ; C, needle into arm ; D, drinks 5 mI. of blood. The stippting represents loss of

consciousness.

Barcroft, H., Edholm, O. G. (1945) J. Physiol. 104, 161. McMichael, J., Sharpey-Schafer, E. P. (1944) Lancet, —

—

i, 489.

T. G., Russell, A. E. (1905) J. Physiol. 32, xlvii. Lewis, T. (1932) Brit. med. J. i, 873.

Brodie,

AA

2