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DECALCIFIED IVORY DISCS FOR END TO END AND LATERAL ANASTOMOSIS OF THE INTESTINE.
522 those which are poured into the blood bv glands baving an internal secretion, such as the thyroid. For all organs, even those which like muscles and nerves are not glandular, have an action on the blood comparable to that of the yeast plant, which modifies the fluid in which it lives by the substances which it removes from or adds to it. It is to a knowledge ef the processes which occur in the protoplasm of the cells in the intestinal wall and liver and of the enzymes by whicti tbei-e processes are in all probability carried out that we must look for an explanation of the conversion of the poisonous albumoses formed during digestion into innocuous albumins, and of dangerous enzymes into harmless zymogns. Moreover, it seems to me that it is by researches into the nature and action of the enzymes not only of microbes, but in the various tissues of the body in higher animals, that we shall learn how the microbes, like the enzymes of the intestinal canal, produce poisonous albumoses, and how the tissues, like the cells of the intestinal walls or liver, convert ihem into harmless or even protective subs ;ances. In this way we may hope to obtain an explanation of toxins and antitoxins, of pathogenesis and immunity, as well as of the nature of diseases unconnected with the presence of microbes, such as diabetes. Twenty three years ago I attempted to obtain a glycolytic enzyme from muscie, in order to enable diabetic pitlentia to unlike the sugar in their b’ood. My attempt was unsuccessful, but we may still hope that by other methods we may obtain from animal organs various enzymes, the administration of which may prove as useful in other diseases as the thyroid gland in myxcedema.
i:is somewhat at variance with the facts, seeing that when, for i:,nstance, he carries out pylorectomy he is obliged to make ttwo sutures, one in the duodenum and another in the pylorus. 1rhe same happens in ileo-colostomy after excision of the ccæcum, and, finally, in the three sizes in which they are: cconstructed the buttons are too large for the diameters of the toowel of children, which is a great drawback, as obstructtions are very common during childhood. Neither cac. t;he system of using decalcified bones of different forms be as in no case where they are employed’ r:ecommended, ccan suture be dispensed with, and the operation becomes ttoo prolonged. The majority of operators employ suture: aalone, giving the preference to that of Czerny-Lembert. I rlave for a long time sought for a substance which should jjoin the serous coat of the bowel and be ultimately digested aafter producing a perfect cicatrisation, but without giving For over three years my; ruse to any stenosis whatever. researches have lasted, and after vainly trying ox bones, tthe ribs of whales, and other substances, I thought, o)f decalcifying pieces of ivory of different sises, so that tthey might be large enough for my purpose after being pprepared, as ivory, like bone, becomes reduced to halt ita dimensions under decalcification. I had some pieces. o)f decalcified ivory turned in concavo-convex sbape& ((Fig. 1, A B), and cf different sizes, from 8 millimetre FIG. 1.
Practical medicine depends on physiology, pharmacology, and pathology, but all three are tending to become more and more sub-divisions of the wider and all-embracing science of chemistry. It is to a chemist, Pasteur, that we owe the wonderful development of pathology within the last quarter of a century, and we may fairly regard his fellowcountryman, Lavoisier, as the founder of this science. Men from all countries, and especially from Germany, have aided its devtlopment ; but it seems fitting that at this Congress, io acknowledging our obligaions to this science, we should not omic to mention that at its head now stands a Russian, Menrleleef, whose marvellous prescience enabled him to predict the existence of elements which were then unknown, and even to describe their properties more correctly than tnuse who first verified his predictions by obtaining the When we consider that little substances themselves. more than a hundred years have elapsed i-ince the time of Lavoisier, and contemplate the vast benefit. which medicine and its allied scierces have denied from chemistry during this time, our hopes cannot be otherwise than great for the centuries to come.
’-
Decalcified
DECALCIFIED IVORY DISCS FOR ENDTO END AND LATERAL ANASTOMOSIS OF THE INTESTINE.1 BY
DR.
R.
MARTIN
GIL,
MEDICAL DIRECTOR OF THE "NOBLE" HOSPITAL OF MALAGA ; CORRESPONDING MEMBER OF THE ROYAL ACADEMIES OF MEDICINE OF MADRID AND BARCELONA, ETC.
OF late years many eminent surgeons have made a special study of intestinal surgexy with the result that important improvements have been effected in the treatment with a correspondingly greater number of successful operations. These improvements notwithstanding have not yet reached such a state of perfection as in other operations on the abdomen. The chief objection to Murphy’s button is that a foreign body is introduced into the intestine, which may, if not expelled with the motions, itself prove a source of great danger to the patient. It is doubtless for t, is reason that the anastomotic button has not come into general use in Europe, and when some operators do employ it it is because they have nothing better to use. These buttons further possess the dangerous property d causi g stenosis in the place where thfy are applitd to the bowel, for the reason that the circumference of the button is u,ual1y smaller than that of the place where it. is fixed. Dr. Murphy states that with his system there is no need for suture, which assertion 1
Abstract of paper read at the International Medical Congress
Moscow.
at
ivory discs; (’7)
stretched apart to show the elasticy (e) in section. to 6 centimetres in diameter. One piece is furnished with a short hollow stem or shank, to which the other piece is adjusted. The thickness of the pieces is proportioned to their circumference Beside the central hole there are two other very small orifices through which thin elastic bands pass that serve to join the pieces, thus. forming a disc, as in c These bands exercise a moderate pressure intended to produce atrophy of the tissue placed between the two pieces while not causing gangrene of the intestine. These bands are tied together with a firm knot.. while the ends, to avoid the loosening of this knot beforecicatrisation takes place, are also bound together with a, silk thread. Met7tod of operating ; end to-end junct’ion of the intestine.The bowel is gently emptied by the fingers at the point o? operation and clamps are applied. When the bowel is cut, through a continuous suture is inserted in it at one end ;.a. cup is introduced, the mouth of the bowel is drawn together, and the thread is tied. At the outer end the same thing is done, and the cups are drawn together by the elastic bands, thus producing a perfect junction of the serous coats of the two ends of the bowel. A pOlticl1 of the ileum was resected in a dog and the ends joined by the discs. The time pent. on the anastomosis of the bowel was six minutes, and the whole operation lasted eighteen minutes. The anima:’ rapidly convalesced, and in four days was well. ’lhree weeks later I operated again and removed the piece of’ intestine where the junction had been effected. No trace of the disc could be found, and no constriction of the bowel had occurred. When very large discs are required I use.: three or four elastic bands to ensure their fitting together round the circumference of the boweL .
523 Ileo-colostomy (end-to-end anastomosis) had not pre- for long periods manifestations of dyspepsia were usually viously been possible without employing sutures, but by my absent. In 46 cases I found no notable evidence of method this result is obtained as effectually as in other dyspepsia, paroxysmal or persistent. It was remarkable operations. A cup of corresponding diameter is fixed in the that an individual whose heart was beatirg more than ileum, and in the colon another of larger size to adapt itself 200 times in a minute should manifest no symptoms of to its circumference. On the union of the two cups drawn distress whatever, but be occupied with his or her usual together by the elastic bands the adjustment of the ileum to avocation. In cases manifesting a rate of heart pulsation of
the colon is perfect. In one experiment the cæcum was 192 and of 260 per minute I have observed a perfect absence resected and a cup 8 millimetres in diameter inserted in the of dyspnoea and of any signs of distress, the functions of ileum, and one of 12 millimetres in the colon, the larger cup digestion being to all seeming normally performed. In one-
having no central stalk ;
the two pieces of bowel were easily approximated, and after the operation, which lasted five minutes, the dog recovered completely. A fortnight later
third of my cases there were no subjective symptoms of disorder of circulation, respiration, or digestion, though the condition of rapid heart continued. In another third severe pain at the præcordium was experienced, but there was no of indigestion. It is clear that dyspepsia stands complaint in no defined relation with the degree of tachycardia. Group 11,, Tachycardia associated with some of the symptoms of Basedow’s (Graves’s) disease.-In these cases I found gastro-intestinal symptoms to be evidenced with a high degree of frequency. The association with the recognised signs of exophthalmic goitre might be marked or slight. In 40 per cent. of my cases the three cardinal signs of the affection-exophthalmos, enlarged thyroid, and persistently rapid heart-were present. In 31 per cent. the exophtbalmos was not manifested, and in 20 per cent. the symptoms occured without thyroid enlargement. Muscular were manifested in the great majority of cases. manifested in most of these cases was The form of dyspepsia It occurred in attacks of the nature of gastroparoxysmal.
tremors
intestinal crisis characterised or
vomiting,
extreme
by epigastric pain, retching,
flatulence, and in
some
cases
During the intervals there were no obvious disturbances of digestion and of necessity no wasticg. In another section of the cases, though in these paroxysmal dyspepsia might not be manifested, there was extreme wasting. Cases manifesticg very marked wasting constitute diarrhoea.
the abdomen was opened and a perfect cicatrix without any stenosis was found. The same method is employed in gastro-enterostomy, in which a large cup is inserted into the stomach and a small one into the duodenum. The junction of the two serous coats is thus complete. Lateral anastomosis is effected quite as easily. Cholecystenterostomy is performed with discs of the sizes required, according as the operator wishes to make larger or smaller the opening between the gall-bladder and the duodenum to ensure the escape of the bile. It might happen that an extra large incision might be required in the gall.bladder to remove a bulky gall-stone ; in this case a large cup might be placed in that organ and a small one in the bowel, as is done in ileo-
colostomy.
well-marked section in Basedow’s disease, and I have found this sign to be of unfavourable import. Consecutive or concurrent changes in the heart bear no relation with the manifestations of dyspepsia. I have noted that dilatation of the heart is more frequently manifested when the degree of tachycardia is slight. Conversely, when the heart-rate exceeds 150 per minute the heart is in most cases found to be small in outline. The paroxysmal dyspepsia is in no relation with the degree of tachycardia or with the co-existing changes in the heart. I have found that a considerable number of of tachycardia have cases been initiated by influenza.. In 100 cases observed by myself in which symptoms referred to the heart were consequent upon the infection of influenza I found that persistent tachycardia was manifested in thirty-seven. In many of these there were present some of the signs of Basedow’s disease, and I obtained abundant evidence to show that the complete ensemble of the affection could be initiated by influenza. In five of the thirty-seven cases of postinfluenzal tachycardia there were well-marked cnses of dyspepsia. The symptoms of the attacks were flatulence, a
The number of dogs I have operated upon is twenty-two, and on them I have made twenty-three experiments. Among these two dogs died ; one after anastomosis of the ileum with the colon lived forty hours, and then died from volvulus ; the other death occurred from collapse after resection of a portion of the colon. The discs should form a collection of twenty-seven sizes, from 60 millimetres, the largest, to 8 millimetres, the smallest. Such are the results of the experiments carried out by me with my discs of decalcified ivory. I have not yet had the nausea, gastralgia, and diarrheea accompanied by dyspnœa. They occurred periodically without obvious provoking cause, opportunity of using them on human beings. and in many cases were manifested during the night. The Malaga. signs were so suggestive of a neurosis that I termed them "vagus storms." It is a question for consideration whether the failure of nutrition in the section of cases attended with A NOTE ON NEUROPATHIC DYSPEPSIA wasting, but not with paroxysmal dyspepsia, is not also due to a disorder of the central nt rvous mechanism. AND ITS CORRELATIONS WITH DISGroup III,, Paroxysmal tachycardia -It is a matter of TURBANCES OF THE RHYTHM common experience that attacks of palpitation of the heart OF THE HEART.1 are frequently associated with symptoms cf dyspepsia. It is a question to be debated whether in such cases the gastroBY A. ERNEST SANSOM, M.D., F.R.C P. LOND., intestinal irritation is the cause which disturbs the cardiac PHYSICIAN TO THE LONDON HOSPITAL; PRESIDENT OF THE MEDICAL reflex or whether both these symptoms are of central nervous SOCIETY OF LONDON, ETC. origin. I have considered this question in relation with the THIS communication contains a summary of the con- form of paroxysmal dyspepsia which is independent of disturbances of the heart-rhythm. clusions I have arrived at from a clinical study of a large Group IV., Persistent cardiac arhythmia -As in the case I number of cases in which there were manifested perversions of persistent tachycardia, so in that of persistent arhythmiaof the rhythm of the heart in the sense of morbid accelera- even in the most extreme forms-there may be no manifestation (tachycardia), irregularity of action (arhythmia cordis), tions of disorder of digestion. In many cases of extreme or abnormally slow action (bradycardia). irregularity of the heart’s action, as indicated by the spbygmcand other precise methods of investigation, there has graphic group I., essential tachycardia.-In those cases in which or of ill performance there was an abnormally rapid action of the heart persisting been no evidence of bodily discomfort of the functions of digestion. In such cases it is of tl e 1 Abstract of a paper read at the International Medical Congress at highest importance that the attention of the patient should not be directed to the irregular action of the heart. Such Moscow.
GroupI.,Essential tachycardia.-In thosecasesin which
i:is somewhat at variance with the facts, seeing that when, for i:,nstance, he carries out pylorectomy he is obliged to make ttwo sutures, one in the duodenum and another in the pylorus. 1rhe same happens in ileo-colostomy after excision of the ccæcum, and, finally, in the three sizes in which they are: cconstructed the buttons are too large for the diameters of the toowel of children, which is a great drawback, as obstructtions are very common during childhood. Neither cac. t;he system of using decalcified bones of different forms be as in no case where they are employed’ r:ecommended, ccan suture be dispensed with, and the operation becomes ttoo prolonged. The majority of operators employ suture: aalone, giving the preference to that of Czerny-Lembert. I rlave for a long time sought for a substance which should jjoin the serous coat of the bowel and be ultimately digested aafter producing a perfect cicatrisation, but without giving For over three years my; ruse to any stenosis whatever. researches have lasted, and after vainly trying ox bones, tthe ribs of whales, and other substances, I thought, o)f decalcifying pieces of ivory of different sises, so that tthey might be large enough for my purpose after being pprepared, as ivory, like bone, becomes reduced to halt ita dimensions under decalcification. I had some pieces. o)f decalcified ivory turned in concavo-convex sbape& ((Fig. 1, A B), and cf different sizes, from 8 millimetre FIG. 1.
Practical medicine depends on physiology, pharmacology, and pathology, but all three are tending to become more and more sub-divisions of the wider and all-embracing science of chemistry. It is to a chemist, Pasteur, that we owe the wonderful development of pathology within the last quarter of a century, and we may fairly regard his fellowcountryman, Lavoisier, as the founder of this science. Men from all countries, and especially from Germany, have aided its devtlopment ; but it seems fitting that at this Congress, io acknowledging our obligaions to this science, we should not omic to mention that at its head now stands a Russian, Menrleleef, whose marvellous prescience enabled him to predict the existence of elements which were then unknown, and even to describe their properties more correctly than tnuse who first verified his predictions by obtaining the When we consider that little substances themselves. more than a hundred years have elapsed i-ince the time of Lavoisier, and contemplate the vast benefit. which medicine and its allied scierces have denied from chemistry during this time, our hopes cannot be otherwise than great for the centuries to come.
’-
Decalcified
DECALCIFIED IVORY DISCS FOR ENDTO END AND LATERAL ANASTOMOSIS OF THE INTESTINE.1 BY
DR.
R.
MARTIN
GIL,
MEDICAL DIRECTOR OF THE "NOBLE" HOSPITAL OF MALAGA ; CORRESPONDING MEMBER OF THE ROYAL ACADEMIES OF MEDICINE OF MADRID AND BARCELONA, ETC.
OF late years many eminent surgeons have made a special study of intestinal surgexy with the result that important improvements have been effected in the treatment with a correspondingly greater number of successful operations. These improvements notwithstanding have not yet reached such a state of perfection as in other operations on the abdomen. The chief objection to Murphy’s button is that a foreign body is introduced into the intestine, which may, if not expelled with the motions, itself prove a source of great danger to the patient. It is doubtless for t, is reason that the anastomotic button has not come into general use in Europe, and when some operators do employ it it is because they have nothing better to use. These buttons further possess the dangerous property d causi g stenosis in the place where thfy are applitd to the bowel, for the reason that the circumference of the button is u,ual1y smaller than that of the place where it. is fixed. Dr. Murphy states that with his system there is no need for suture, which assertion 1
Abstract of paper read at the International Medical Congress
Moscow.
at
ivory discs; (’7)
stretched apart to show the elasticy (e) in section. to 6 centimetres in diameter. One piece is furnished with a short hollow stem or shank, to which the other piece is adjusted. The thickness of the pieces is proportioned to their circumference Beside the central hole there are two other very small orifices through which thin elastic bands pass that serve to join the pieces, thus. forming a disc, as in c These bands exercise a moderate pressure intended to produce atrophy of the tissue placed between the two pieces while not causing gangrene of the intestine. These bands are tied together with a firm knot.. while the ends, to avoid the loosening of this knot beforecicatrisation takes place, are also bound together with a, silk thread. Met7tod of operating ; end to-end junct’ion of the intestine.The bowel is gently emptied by the fingers at the point o? operation and clamps are applied. When the bowel is cut, through a continuous suture is inserted in it at one end ;.a. cup is introduced, the mouth of the bowel is drawn together, and the thread is tied. At the outer end the same thing is done, and the cups are drawn together by the elastic bands, thus producing a perfect junction of the serous coats of the two ends of the bowel. A pOlticl1 of the ileum was resected in a dog and the ends joined by the discs. The time pent. on the anastomosis of the bowel was six minutes, and the whole operation lasted eighteen minutes. The anima:’ rapidly convalesced, and in four days was well. ’lhree weeks later I operated again and removed the piece of’ intestine where the junction had been effected. No trace of the disc could be found, and no constriction of the bowel had occurred. When very large discs are required I use.: three or four elastic bands to ensure their fitting together round the circumference of the boweL .
523 Ileo-colostomy (end-to-end anastomosis) had not pre- for long periods manifestations of dyspepsia were usually viously been possible without employing sutures, but by my absent. In 46 cases I found no notable evidence of method this result is obtained as effectually as in other dyspepsia, paroxysmal or persistent. It was remarkable operations. A cup of corresponding diameter is fixed in the that an individual whose heart was beatirg more than ileum, and in the colon another of larger size to adapt itself 200 times in a minute should manifest no symptoms of to its circumference. On the union of the two cups drawn distress whatever, but be occupied with his or her usual together by the elastic bands the adjustment of the ileum to avocation. In cases manifesting a rate of heart pulsation of
the colon is perfect. In one experiment the cæcum was 192 and of 260 per minute I have observed a perfect absence resected and a cup 8 millimetres in diameter inserted in the of dyspnoea and of any signs of distress, the functions of ileum, and one of 12 millimetres in the colon, the larger cup digestion being to all seeming normally performed. In one-
having no central stalk ;
the two pieces of bowel were easily approximated, and after the operation, which lasted five minutes, the dog recovered completely. A fortnight later
third of my cases there were no subjective symptoms of disorder of circulation, respiration, or digestion, though the condition of rapid heart continued. In another third severe pain at the præcordium was experienced, but there was no of indigestion. It is clear that dyspepsia stands complaint in no defined relation with the degree of tachycardia. Group 11,, Tachycardia associated with some of the symptoms of Basedow’s (Graves’s) disease.-In these cases I found gastro-intestinal symptoms to be evidenced with a high degree of frequency. The association with the recognised signs of exophthalmic goitre might be marked or slight. In 40 per cent. of my cases the three cardinal signs of the affection-exophthalmos, enlarged thyroid, and persistently rapid heart-were present. In 31 per cent. the exophtbalmos was not manifested, and in 20 per cent. the symptoms occured without thyroid enlargement. Muscular were manifested in the great majority of cases. manifested in most of these cases was The form of dyspepsia It occurred in attacks of the nature of gastroparoxysmal.
tremors
intestinal crisis characterised or
vomiting,
extreme
by epigastric pain, retching,
flatulence, and in
some
cases
During the intervals there were no obvious disturbances of digestion and of necessity no wasticg. In another section of the cases, though in these paroxysmal dyspepsia might not be manifested, there was extreme wasting. Cases manifesticg very marked wasting constitute diarrhoea.
the abdomen was opened and a perfect cicatrix without any stenosis was found. The same method is employed in gastro-enterostomy, in which a large cup is inserted into the stomach and a small one into the duodenum. The junction of the two serous coats is thus complete. Lateral anastomosis is effected quite as easily. Cholecystenterostomy is performed with discs of the sizes required, according as the operator wishes to make larger or smaller the opening between the gall-bladder and the duodenum to ensure the escape of the bile. It might happen that an extra large incision might be required in the gall.bladder to remove a bulky gall-stone ; in this case a large cup might be placed in that organ and a small one in the bowel, as is done in ileo-
colostomy.
well-marked section in Basedow’s disease, and I have found this sign to be of unfavourable import. Consecutive or concurrent changes in the heart bear no relation with the manifestations of dyspepsia. I have noted that dilatation of the heart is more frequently manifested when the degree of tachycardia is slight. Conversely, when the heart-rate exceeds 150 per minute the heart is in most cases found to be small in outline. The paroxysmal dyspepsia is in no relation with the degree of tachycardia or with the co-existing changes in the heart. I have found that a considerable number of of tachycardia have cases been initiated by influenza.. In 100 cases observed by myself in which symptoms referred to the heart were consequent upon the infection of influenza I found that persistent tachycardia was manifested in thirty-seven. In many of these there were present some of the signs of Basedow’s disease, and I obtained abundant evidence to show that the complete ensemble of the affection could be initiated by influenza. In five of the thirty-seven cases of postinfluenzal tachycardia there were well-marked cnses of dyspepsia. The symptoms of the attacks were flatulence, a
The number of dogs I have operated upon is twenty-two, and on them I have made twenty-three experiments. Among these two dogs died ; one after anastomosis of the ileum with the colon lived forty hours, and then died from volvulus ; the other death occurred from collapse after resection of a portion of the colon. The discs should form a collection of twenty-seven sizes, from 60 millimetres, the largest, to 8 millimetres, the smallest. Such are the results of the experiments carried out by me with my discs of decalcified ivory. I have not yet had the nausea, gastralgia, and diarrheea accompanied by dyspnœa. They occurred periodically without obvious provoking cause, opportunity of using them on human beings. and in many cases were manifested during the night. The Malaga. signs were so suggestive of a neurosis that I termed them "vagus storms." It is a question for consideration whether the failure of nutrition in the section of cases attended with A NOTE ON NEUROPATHIC DYSPEPSIA wasting, but not with paroxysmal dyspepsia, is not also due to a disorder of the central nt rvous mechanism. AND ITS CORRELATIONS WITH DISGroup III,, Paroxysmal tachycardia -It is a matter of TURBANCES OF THE RHYTHM common experience that attacks of palpitation of the heart OF THE HEART.1 are frequently associated with symptoms cf dyspepsia. It is a question to be debated whether in such cases the gastroBY A. ERNEST SANSOM, M.D., F.R.C P. LOND., intestinal irritation is the cause which disturbs the cardiac PHYSICIAN TO THE LONDON HOSPITAL; PRESIDENT OF THE MEDICAL reflex or whether both these symptoms are of central nervous SOCIETY OF LONDON, ETC. origin. I have considered this question in relation with the THIS communication contains a summary of the con- form of paroxysmal dyspepsia which is independent of disturbances of the heart-rhythm. clusions I have arrived at from a clinical study of a large Group IV., Persistent cardiac arhythmia -As in the case I number of cases in which there were manifested perversions of persistent tachycardia, so in that of persistent arhythmiaof the rhythm of the heart in the sense of morbid accelera- even in the most extreme forms-there may be no manifestation (tachycardia), irregularity of action (arhythmia cordis), tions of disorder of digestion. In many cases of extreme or abnormally slow action (bradycardia). irregularity of the heart’s action, as indicated by the spbygmcand other precise methods of investigation, there has graphic group I., essential tachycardia.-In those cases in which or of ill performance there was an abnormally rapid action of the heart persisting been no evidence of bodily discomfort of the functions of digestion. In such cases it is of tl e 1 Abstract of a paper read at the International Medical Congress at highest importance that the attention of the patient should not be directed to the irregular action of the heart. Such Moscow.
GroupI.,Essential tachycardia.-In thosecasesin which