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Mercury—Its rôle in intestinal decompression tubes
MERCURY-ITS
RbLE
IN INTESTINAL TUBES
MEYER
0.
CANTOR,
DECOMPRESSION
M.D.
DETROIT, MICHIGAN
T
HE rBIe of mercury m the baIIoon of intestina1 decompression tubes appears to be misunderstood. Most surgeons are under the erroneous impression that it is the weight of the mercury that carries the intestina1 decompression tube down the gastrointestina1 tract. The effect of gravity upon the weighted head of the tube is thought to constitute the propuIsive mechanism. The use of mercury in intestina1 obstruction is not new. One hundred fifty years ago mercury was used by mouth in its free form in the treatment of bowe1 obstruction. In the Index of the Surgeon General from the years I 780l,~*~ to 1850~3~3”no Iess than fifty articIes can be found describing the action and use of metaIIic mercury by mouth in the treatment of bowe1 obstruction. AIthough this method of treatment feII into disrepute for obvious reasons, certain fundamental points were Iearned by these surgeons. First, it was not the weight of the mercury that was of vaIue, but it was the fluidity, the IabiIity, the very “quick-siIver” quaIities of the mercury and its marked power of cohesion that were the desirabIe physica properties of the mercury. Further, it was found that Iiquid mercury was compIeteIy innocuous in the gastrointestina1 tract. These two points constitute the most desirabIe physica properties of mercury. The first use of mercury in a gastroduodena1 tube appeared in 1928 with the publication by Wilkins’ of a mercury weighted gastroduodena1 tube. This tube was 3{s inch in diameter and the mercury was packed soIidIy into the head end of the tube. (Fig. I.) An examination of this figure, readiIy discIoses the obvious fact that the onIy physica property of mercury
utiIized here was the weight. Because the mercury was cIoseIy confined in so smaI1 a space, there was no opportunity for the IabiIity and cohesive power of mercury to be utiIized. The very titIe of the paper indicates quite cIearIy that the weight of the mercury was the prime object. The next reference to the use of mercury in intestina1 decompression tubes was the paper by Harris* and the work of Sivertsen,g in which the mercury was pIaced into the baIIoon of a MiIIer-Abbott tube in an effort to weight it and to get the effect of gravity upon the “weighted” head of the tube. Here again, we note that it is weight that was the chief property desired. HarrislO in his singIe Iumen tube used the same position of the baIIoon along the shaft of the dista1 end of the tube (Fig. 2), but placed 4 cc. of mercury in the balloon. It should be quite evident from an examination of Figure 2 that as long as the shaft of the tube passes through the balIoon containing the mercury there can be no The shaft of the “free-fIow” of mercury. tube must of necessity Iimit the Iability of the mercury with the resuIt that again the only physica property of the mercury utiIized wouId be its weight* and the effect of gravity upon its weighted head. If it were mereIy weight that was desired in the head end of an intestinal decompression tube, there are other eIements that are heavier than mercury and hence more desirable from that point of view. An examination of the tabIe of eIements and their atomic weights, l1 disclosed the fact that there are eight eIements whose atomic *The PiIIing Company in their advertisements in the Annals of Surgery advertise the “Harris hlercury Weighted Tube.” Here again, WC find weight as the essential point.
690
VOI.. LXXIII.
No. 6
Cantor-Mercury
in Intestinal
Tubes
FIG. I. In the Wilkins
tube the mercury is tightly pckcd into the distal end of a 9if, inch t&c; weight only is utilized here. No mobility of the mercury possible.
weights exceed that of mercury with an atomic weight of 200.61. Some of these eIements such as radium (atomic wt. 22q.93), radon (atomic wt. 222), and thorium (atomic wt. 232.15) cannot be used because of their physica property of radioactivity. This property makes their use to weight and the head of an intestina1 decompression tube impossibIe. ThaIIium (atomic wt. 204.39) cannot be used because of its toxicity in the event that the balloon wouId break freeing the thallium into the gastrointestina1 tract. Bismuth (atomic wt. 209) is much too brittIe as a meta and not readiIy avaiIabIe. It has no fluidity or cohesive power that wouId make its use in the head of a tube desirable. The onIy remaining eIement heavier than mercury is Iead (atomic wt. 207.20). If it is weight alone that is desired, why not use Iead which is heavier than mercury? In addition
to being heavy, it is reIativeIy non-toxic in the gastrointestinal tract because it wouId be excreted before much absorbtion couId occur. It should be quite apparent that although Iead is heavier than mercury, its other physica properties of being a soIid mass and inert would not fit it we11 for use in an intestina1 decompression tube which is expected to pass through “sinuous passageways with sphincters” as is found in the gastrointestina1 tract. Mercury, on the other hand, because of its fluidity and cohesive power is eminentIy suitable for use in the baIIoon of an intestinal decompression tube because it literally flows’ downward through narrowed portions of the bowe1 and passes sphincters easily. Since mercury is to be used in the head end of the intestinal decompression tube, such tubes must be constructed to utiIize the physica properties of mercury to the
692
American
Journsl
of Surgery
Cantor-Mercury
B.
in IntestinaI
C.
Tubes
JUNE.
1947
D.
FIG. 2. The tube “heads” illustrated here are: A, Johnston; B, MiIIer-Abbott; c, Harris; D, Cantor. Note the cIose simiIarity between the head of A, B and c. In a11 three the shaft of the tube passes through the baIIoon and the end of the tube is open. Note that in the Cantor tube a Ioose baIIoon is applied at the tip.
utmost and not mereIy its weight. Metallic mercury is Iiquid even at the Iowest temperatures. It is a coherent, mobiIe Iiquid, which does not wet gIass or objects pIaced in it. It remains Iiquid under a wide range of temperatures from -39 to pIus 360. It remains unchanged in &y air, oxygen, nitrous oxide and carbon dioxide. but in damp air it sIowIy becomes coated with a fiIm of mercurous oxide which is not particuIarIy important when used in a tube head. Mercury remains unattacked by diIute sulfuric acid and hydrochIoric acid when concentrated has onIy sIight action upon the mercury. This property, its compIete insoIubiIity in acids, makes mercury an exceIIent eIement for use in the head end of the tube because it is compIeteIy non-toxic in its metaIIic form. Reviewing the physica
properties of mercury, we find its lability, marked motihty, and cohesive power as being the most desirabIe features for its use in the head of an intestinal decompression tube, and its non-toxicity and weight as being of secondary importance. To utiIize a11 these physica properties of mercury to their best advantage, it is necessary that the mercury be pIaced in a bag that wiI1 permit a free range of motion. We must not Iimit the free pIay of the mercury in the baIIoon if we are to utiIize these most desirabIe properties. For this reason, we designed a tube (Fig. 3) which permits the maximum utiIization of a11 the physica properties of metaIIic mercury and not mereIy the effect of gravity upon its weighted mass. One notes in examining Figure 3 that the ampIe baIIoon at the
VOL. LXXIII.
No. 6
Cantor-Mercury
terminal end of the single Iumen tube permits a “free-flow” of the metaIIic mercury. With the mercury trapped in a baboon which permits it to flow freeIy, it is onIy necessary to pIace the patient into positions so that the mercury wiII aIways have an opportunity to flow downhi or from sideto-side in order to secure the rapid passage of such a tube far down the gastrointestinal tract. It must be remembered that the tube will not run uphill. When we make the statement, “the tube will not run uphill” we assume that there is no peristaltic activity pushing it along. If the stomach is in tone and peristaltic waves are present, such a tube will rapidIy pass down the gastrointestinal tract without any further ado. However, since we use the tubes in a11 types of intestinal distention many of the patients either have no peristaltic waves or those that are present are in the reverse direction. In such cases, the maximum utiIization of all the physical properties of the mercury and a knowledge of anatomy which permits us to maneuver the patient about so that the part to which the tube head is to go into wiI1 always be downhill, heIps tremendously in securing the downward passage of the intestinal decompression tube. In inserting a tube of this type into the nose, if the head of the patient is hyperextended with the patient on his back, the nasa1 passage runs downhi so that the tube readiIy drops into the nasopharynx. Then, sitting such a patient up and a drink of water resuIts in the baIIoon and tube dropping into the stomach. From this point on, a knowledge of certain fundamenta1 anatomica facts is of great vaIue. When the patient Iies flat on his back, the fundus of the stomach comes to lie posterior to the antral portion. As a resuIt, if the tube is passed and the patient Iies quietIy on his back, the weighted head of the tube wouId drop into the pouch of stomach in the Ieft paravertebrar gutter where the fundus comes to he. Motion of the patient and putting the pyIorus (apex
in 1ntestinaI
Tubes
American Journal or surgery
693
FIG. 3. In the Cantor tube the loose balloon is applied to the end of the tube. This permits a “free-flow” of mercury and permits the utiIization of all the physical properties of the mercurv. It is the mobiIitv. the labilitv and marked cohisive power of the mercury and the motion of the patient that carries this tube down and not merely the effect of gravity upon a weighted mass, aIthough this Iatter effect is also utiIized to its best advantage.
of the stomach funnel) in a position so that it wiI1 be downhill readiIy causes the tube to pass through the pyIorus. To accompIish this turning the patient on his right side makes the pyIorus assume a downhi position. Now if we bear in mind the fact that the first portion of the duodenum is an ascending limb (uphiII), it becomes desirabIe to eIevate the foot of the bed tweIve inches in order that this limb become downhiI1. The second portion of the duodenum runs downward. To utiIize this anatomical fact, we Iower the foot of the bed and put the patient up on a backrest. The third portion of the duodenum runs transversely from right to left. Turning the patient on his Ieft side wouId resuIt in the tube head running down the incline. From this point on, motion of the patient and the free flow of the mercury in the tube head readiIy carries the tube downward. We encourage these patients to move freeIy. The emphasis
694
American Journal of Surgery
Cantor-Mercury
on early ambuIation and motion in bed in recent years has demonstrated its great vaIue in preventing vascular, puImonary and gastrointestina1 compIications. Utilizing the effect of motion of the patient upon a freely flowing metal such as mercury at the head end of an intestina1 decompression tube, great success in its passage has resuIted. CONCLUSIONS I. The physica properties of mercury that make it usefu1 in the “head” of an intestina1 decompression tube are mobiIity, IabiIity and great cohesive power, as we11 as its compIete Iack of toxicity. The weight of the mercury, aIthough helpful, is not the most desirabIe property. 2. To utiIize a11 the desirable physica properties of mercury as a propuIsive mechanism, a singIe Iumen tube with the baIIoon free and ample at the end of the tube, must be used. 3. Motion of the patient not only prevents compIications but also aids immeasurabIy in securing downward passage of the tube.
in IntestinaI
Tubes
JUNE.,917
KEFEKENCES I. ATKINSON, T. G. Mercury
in &us. London M. Gaz., 3 I : @$, 1842~43. 2. Corsox, L. Observation d’une guerison d’ileus par I’cmpIoi du mcrcure coulant. Bull. Sot. de t&d. de Gond., 12: 21-43, 1846. 3. ~IADDEN. An account of what was observed upon opening a person who had taken severa ounces of crude mercury internally, and of a plumb stone lodged in coats of rectum. Phil. Tr. London, 9: 152, 1732-44. 4. ~IA~.IGNON, A. Du
5.
6.
7. 8.
g. IO.
traitement de I’occlusion intestinaIe par le mercure metallique a haut dose. Paril, I 879. EUERS, J. J. II. Ueber den IIcus und seine BehandIung vornemlich durch das lebendige QuecksiIber nebst einem wichtiaen Krankheitsfalle. J. d. pact. Heilk., 68: 3, 1829. ZWINGER, T. hlercurii crudi effectus in colica spasmodica a fecum duritie alvum contumaciter abstruente oriunda. &Iisc. Acad. Nat. Curios. 1687, Norimb. 1707, 2 decuria, 6: 496-521; CoIIect. Acad. d. mem. Dijon., 7: 488-491, 1766. WILKIM, J. A. Mercury weighted stomach tube. J. A. M. A., 9: 395-396, 1928. HARRIS, I;.L. New rapid method of intubation with RliIIer-Abbott tube. J. A. hf. A., 125: 784-785, 1944. SIVERTSEN, 1. Reported by I Iarris, F. I. J. A. hf. A., 126: 718, ,944. IIARRIS, F. I. Intestinal intubation in bowe1 obstruction. Surg., @net. (V Oh., 81: 671-678.
‘Y45. I I. Encyclopaedin
Britannica.
2: 650, 1945.
RbLE
IN INTESTINAL TUBES
MEYER
0.
CANTOR,
DECOMPRESSION
M.D.
DETROIT, MICHIGAN
T
HE rBIe of mercury m the baIIoon of intestina1 decompression tubes appears to be misunderstood. Most surgeons are under the erroneous impression that it is the weight of the mercury that carries the intestina1 decompression tube down the gastrointestina1 tract. The effect of gravity upon the weighted head of the tube is thought to constitute the propuIsive mechanism. The use of mercury in intestina1 obstruction is not new. One hundred fifty years ago mercury was used by mouth in its free form in the treatment of bowe1 obstruction. In the Index of the Surgeon General from the years I 780l,~*~ to 1850~3~3”no Iess than fifty articIes can be found describing the action and use of metaIIic mercury by mouth in the treatment of bowe1 obstruction. AIthough this method of treatment feII into disrepute for obvious reasons, certain fundamental points were Iearned by these surgeons. First, it was not the weight of the mercury that was of vaIue, but it was the fluidity, the IabiIity, the very “quick-siIver” quaIities of the mercury and its marked power of cohesion that were the desirabIe physica properties of the mercury. Further, it was found that Iiquid mercury was compIeteIy innocuous in the gastrointestina1 tract. These two points constitute the most desirabIe physica properties of mercury. The first use of mercury in a gastroduodena1 tube appeared in 1928 with the publication by Wilkins’ of a mercury weighted gastroduodena1 tube. This tube was 3{s inch in diameter and the mercury was packed soIidIy into the head end of the tube. (Fig. I.) An examination of this figure, readiIy discIoses the obvious fact that the onIy physica property of mercury
utiIized here was the weight. Because the mercury was cIoseIy confined in so smaI1 a space, there was no opportunity for the IabiIity and cohesive power of mercury to be utiIized. The very titIe of the paper indicates quite cIearIy that the weight of the mercury was the prime object. The next reference to the use of mercury in intestina1 decompression tubes was the paper by Harris* and the work of Sivertsen,g in which the mercury was pIaced into the baIIoon of a MiIIer-Abbott tube in an effort to weight it and to get the effect of gravity upon the “weighted” head of the tube. Here again, we note that it is weight that was the chief property desired. HarrislO in his singIe Iumen tube used the same position of the baIIoon along the shaft of the dista1 end of the tube (Fig. 2), but placed 4 cc. of mercury in the balloon. It should be quite evident from an examination of Figure 2 that as long as the shaft of the tube passes through the balIoon containing the mercury there can be no The shaft of the “free-fIow” of mercury. tube must of necessity Iimit the Iability of the mercury with the resuIt that again the only physica property of the mercury utiIized wouId be its weight* and the effect of gravity upon its weighted head. If it were mereIy weight that was desired in the head end of an intestinal decompression tube, there are other eIements that are heavier than mercury and hence more desirable from that point of view. An examination of the tabIe of eIements and their atomic weights, l1 disclosed the fact that there are eight eIements whose atomic *The PiIIing Company in their advertisements in the Annals of Surgery advertise the “Harris hlercury Weighted Tube.” Here again, WC find weight as the essential point.
690
VOI.. LXXIII.
No. 6
Cantor-Mercury
in Intestinal
Tubes
FIG. I. In the Wilkins
tube the mercury is tightly pckcd into the distal end of a 9if, inch t&c; weight only is utilized here. No mobility of the mercury possible.
weights exceed that of mercury with an atomic weight of 200.61. Some of these eIements such as radium (atomic wt. 22q.93), radon (atomic wt. 222), and thorium (atomic wt. 232.15) cannot be used because of their physica property of radioactivity. This property makes their use to weight and the head of an intestina1 decompression tube impossibIe. ThaIIium (atomic wt. 204.39) cannot be used because of its toxicity in the event that the balloon wouId break freeing the thallium into the gastrointestina1 tract. Bismuth (atomic wt. 209) is much too brittIe as a meta and not readiIy avaiIabIe. It has no fluidity or cohesive power that wouId make its use in the head of a tube desirable. The onIy remaining eIement heavier than mercury is Iead (atomic wt. 207.20). If it is weight alone that is desired, why not use Iead which is heavier than mercury? In addition
to being heavy, it is reIativeIy non-toxic in the gastrointestinal tract because it wouId be excreted before much absorbtion couId occur. It should be quite apparent that although Iead is heavier than mercury, its other physica properties of being a soIid mass and inert would not fit it we11 for use in an intestina1 decompression tube which is expected to pass through “sinuous passageways with sphincters” as is found in the gastrointestina1 tract. Mercury, on the other hand, because of its fluidity and cohesive power is eminentIy suitable for use in the baIIoon of an intestinal decompression tube because it literally flows’ downward through narrowed portions of the bowe1 and passes sphincters easily. Since mercury is to be used in the head end of the intestinal decompression tube, such tubes must be constructed to utiIize the physica properties of mercury to the
692
American
Journsl
of Surgery
Cantor-Mercury
B.
in IntestinaI
C.
Tubes
JUNE.
1947
D.
FIG. 2. The tube “heads” illustrated here are: A, Johnston; B, MiIIer-Abbott; c, Harris; D, Cantor. Note the cIose simiIarity between the head of A, B and c. In a11 three the shaft of the tube passes through the baIIoon and the end of the tube is open. Note that in the Cantor tube a Ioose baIIoon is applied at the tip.
utmost and not mereIy its weight. Metallic mercury is Iiquid even at the Iowest temperatures. It is a coherent, mobiIe Iiquid, which does not wet gIass or objects pIaced in it. It remains Iiquid under a wide range of temperatures from -39 to pIus 360. It remains unchanged in &y air, oxygen, nitrous oxide and carbon dioxide. but in damp air it sIowIy becomes coated with a fiIm of mercurous oxide which is not particuIarIy important when used in a tube head. Mercury remains unattacked by diIute sulfuric acid and hydrochIoric acid when concentrated has onIy sIight action upon the mercury. This property, its compIete insoIubiIity in acids, makes mercury an exceIIent eIement for use in the head end of the tube because it is compIeteIy non-toxic in its metaIIic form. Reviewing the physica
properties of mercury, we find its lability, marked motihty, and cohesive power as being the most desirabIe features for its use in the head of an intestinal decompression tube, and its non-toxicity and weight as being of secondary importance. To utiIize a11 these physica properties of mercury to their best advantage, it is necessary that the mercury be pIaced in a bag that wiI1 permit a free range of motion. We must not Iimit the free pIay of the mercury in the baIIoon if we are to utiIize these most desirabIe properties. For this reason, we designed a tube (Fig. 3) which permits the maximum utiIization of a11 the physica properties of metaIIic mercury and not mereIy the effect of gravity upon its weighted mass. One notes in examining Figure 3 that the ampIe baIIoon at the
VOL. LXXIII.
No. 6
Cantor-Mercury
terminal end of the single Iumen tube permits a “free-flow” of the metaIIic mercury. With the mercury trapped in a baboon which permits it to flow freeIy, it is onIy necessary to pIace the patient into positions so that the mercury wiII aIways have an opportunity to flow downhi or from sideto-side in order to secure the rapid passage of such a tube far down the gastrointestinal tract. It must be remembered that the tube will not run uphill. When we make the statement, “the tube will not run uphill” we assume that there is no peristaltic activity pushing it along. If the stomach is in tone and peristaltic waves are present, such a tube will rapidIy pass down the gastrointestinal tract without any further ado. However, since we use the tubes in a11 types of intestinal distention many of the patients either have no peristaltic waves or those that are present are in the reverse direction. In such cases, the maximum utiIization of all the physical properties of the mercury and a knowledge of anatomy which permits us to maneuver the patient about so that the part to which the tube head is to go into wiI1 always be downhill, heIps tremendously in securing the downward passage of the intestinal decompression tube. In inserting a tube of this type into the nose, if the head of the patient is hyperextended with the patient on his back, the nasa1 passage runs downhi so that the tube readiIy drops into the nasopharynx. Then, sitting such a patient up and a drink of water resuIts in the baIIoon and tube dropping into the stomach. From this point on, a knowledge of certain fundamenta1 anatomica facts is of great vaIue. When the patient Iies flat on his back, the fundus of the stomach comes to lie posterior to the antral portion. As a resuIt, if the tube is passed and the patient Iies quietIy on his back, the weighted head of the tube wouId drop into the pouch of stomach in the Ieft paravertebrar gutter where the fundus comes to he. Motion of the patient and putting the pyIorus (apex
in 1ntestinaI
Tubes
American Journal or surgery
693
FIG. 3. In the Cantor tube the loose balloon is applied to the end of the tube. This permits a “free-flow” of mercury and permits the utiIization of all the physical properties of the mercurv. It is the mobiIitv. the labilitv and marked cohisive power of the mercury and the motion of the patient that carries this tube down and not merely the effect of gravity upon a weighted mass, aIthough this Iatter effect is also utiIized to its best advantage.
of the stomach funnel) in a position so that it wiI1 be downhill readiIy causes the tube to pass through the pyIorus. To accompIish this turning the patient on his right side makes the pyIorus assume a downhi position. Now if we bear in mind the fact that the first portion of the duodenum is an ascending limb (uphiII), it becomes desirabIe to eIevate the foot of the bed tweIve inches in order that this limb become downhiI1. The second portion of the duodenum runs downward. To utiIize this anatomical fact, we Iower the foot of the bed and put the patient up on a backrest. The third portion of the duodenum runs transversely from right to left. Turning the patient on his Ieft side wouId resuIt in the tube head running down the incline. From this point on, motion of the patient and the free flow of the mercury in the tube head readiIy carries the tube downward. We encourage these patients to move freeIy. The emphasis
694
American Journal of Surgery
Cantor-Mercury
on early ambuIation and motion in bed in recent years has demonstrated its great vaIue in preventing vascular, puImonary and gastrointestina1 compIications. Utilizing the effect of motion of the patient upon a freely flowing metal such as mercury at the head end of an intestina1 decompression tube, great success in its passage has resuIted. CONCLUSIONS I. The physica properties of mercury that make it usefu1 in the “head” of an intestina1 decompression tube are mobiIity, IabiIity and great cohesive power, as we11 as its compIete Iack of toxicity. The weight of the mercury, aIthough helpful, is not the most desirabIe property. 2. To utiIize a11 the desirable physica properties of mercury as a propuIsive mechanism, a singIe Iumen tube with the baIIoon free and ample at the end of the tube, must be used. 3. Motion of the patient not only prevents compIications but also aids immeasurabIy in securing downward passage of the tube.
in IntestinaI
Tubes
JUNE.,917
KEFEKENCES I. ATKINSON, T. G. Mercury
in &us. London M. Gaz., 3 I : @$, 1842~43. 2. Corsox, L. Observation d’une guerison d’ileus par I’cmpIoi du mcrcure coulant. Bull. Sot. de t&d. de Gond., 12: 21-43, 1846. 3. ~IADDEN. An account of what was observed upon opening a person who had taken severa ounces of crude mercury internally, and of a plumb stone lodged in coats of rectum. Phil. Tr. London, 9: 152, 1732-44. 4. ~IA~.IGNON, A. Du
5.
6.
7. 8.
g. IO.
traitement de I’occlusion intestinaIe par le mercure metallique a haut dose. Paril, I 879. EUERS, J. J. II. Ueber den IIcus und seine BehandIung vornemlich durch das lebendige QuecksiIber nebst einem wichtiaen Krankheitsfalle. J. d. pact. Heilk., 68: 3, 1829. ZWINGER, T. hlercurii crudi effectus in colica spasmodica a fecum duritie alvum contumaciter abstruente oriunda. &Iisc. Acad. Nat. Curios. 1687, Norimb. 1707, 2 decuria, 6: 496-521; CoIIect. Acad. d. mem. Dijon., 7: 488-491, 1766. WILKIM, J. A. Mercury weighted stomach tube. J. A. M. A., 9: 395-396, 1928. HARRIS, I;.L. New rapid method of intubation with RliIIer-Abbott tube. J. A. hf. A., 125: 784-785, 1944. SIVERTSEN, 1. Reported by I Iarris, F. I. J. A. hf. A., 126: 718, ,944. IIARRIS, F. I. Intestinal intubation in bowe1 obstruction. Surg., @net. (V Oh., 81: 671-678.
‘Y45. I I. Encyclopaedin
Britannica.
2: 650, 1945.