METHODS OF UNITING DIVIDED INTESTINE,

505 it is interesting to note in connexion with Professor W’right’s statements with regard to urticaria and weakened power of blood coagulability that this patient has suffered from urticaria off and on since she can remember and that this has greatly improved under treatment by calcium chloride.

OF POST - OPERATIVE HÆMATEMESIS.

A CASE

BY ARTHUR H. ASSISTANT SURGEON,

SUSSEX

BUCK, F.R.C.S. EDIN.,

COUNTY

Brighton.

HOSPITAL; SURGEON, BRIGHTON

___________________

AND HOVE THROAT AND EAR HOSPITAL.

METHODS

following case, which I saw with Mr. E. H. Sweet of Uckfield in April of this year and afterwards operated on, is, THE

I

think, of interest,

as

the records of similar

cases are

OF

UNITING

DIVIDED

INTESTINE, WITH SPECIAL REFERENCE

not

THAT

numerous.

TO A NEW BONE BOBBIN FOR PURPOSE. 1

A spinster, aged 53 years, had suffered from pelvic pain, BY E. STANMORE BISHOP, F.R.C.S. ENG., HONORARY SURGEON TO THE ANCOATS HOSPITAL, MANCHESTER. menorrhagia, and metrorrhagia for 23 years. On May 6th, ether having been administered by Mr. Morris Rigby, the METHODS of union are divisible into four main abdomen was opened and the patient was placed in classes : to on The was found be suture moveable suture ; (1) forceps ; simple (2) Trendelenberg’s position. pelvis occupied by an adherent mass consisting of (1) the (3) suture on absorbable material, usually decalcified bone ; Fallopian tubes dilated to the size of small intestines and (4) metallic couplers. In simple suturing probably Lembert’s suture holds the and coiled over and amongst the other structures ; (2) a left ovarian cyst of the size of an orange and first place, although the principle upon which it is based, adherent to the anterior surface of the uterus ; (3) the advisability of non-perforation of the mucous membrane, the right ovary, small and atrophied ; and (4) the is not now so firmly held as it was at the time I first uterus, which was completely retroflexed and presented advocated a suture which penetrated the entire wall. A in its posterior wall a fibroid as large as a cricket similar method has lately been widely adopted in America. These structures were to one ball. another, In all cases, even in some of those treated firmly adherent by the fourth to the bladder in front, and to the rectum behind. The . of some kind is necessary. broad ligaments were indistinguishable and on removing the method, suturing Suturing on moveable forceps, as those of Laplace and left tube the ureter on that side was exposed for four inches. is easy and rapid, but they have the defect that no O’Hara, After considerable difficulty the pelvis was cleared and flaps from the entrance of fascal matters between the of peritoneum were sutured so as to leave a smooth-walled protection lines of union is afforded by them during the dangerous The and operation was necessarily a severe one cavity. I am not sure that after operation. lasted for two hours. Mr. Sweet kindly and most ably period immediately the crushing of the ends produced by their use is directly assisted me. since it should be an advantage if these ends, During the first 36 hours after the operation there was harmful, which form an internal flange, afterwards could be removed considerable abdominal pain and sickness occurred several that such necrosis went no times. Morphia, to which the patient was accustomed, was by necrosis, provided always further. however, from the recorded by analogy, Judging administered hypodermically three times in quarter-grain results of pressure necrosis produced by Murphy’s button, doses. Flatus was freely passed and the abdomen was never this is not always to be implicitly Jelied upon. distended, nor were the abdominal walls fixed. The pulseMetallic couplers, of which Murphy’s is the type, have the rate did not exceed 88 and the highest temperature was of rapidity in application, an advantage 100° F. 36 hours after the operation the patient vomited great advantage which, I believe, must always render it unlikely that they a large quantity of altered blood (coffee-coloured) and a can be entirely set aside, but so many cases are now to be second similar quantity four hours later ; the temperature fell found in the literature of the subject in which unpleasant to subnormal but the pulse was not affected. Mr. Sweet should later results have occurred that I conceive that prescribed a lead and opium pill, and the following never be chosen unless the element of time is they of the first day. as the vomiting of’ blood, attended by very severe importance. Progressive necrosis of the gut starting from retching, continued, four doses of liquor chloride of the line of union and spreading towards some unprotected adrenalin were administered hourly, the first two doses absolute later obstruction, retrograde movement!-’, as consisting of 30 minims each and the last two of 10 point, backwards into the stomach in gastro-enterostomy, and other minims. Mr. Sweet also gave four grains of calomel, incidents of a like kind increase unnecessarily the anxiety of followed by two grains of calomel twice at intervals of the operator and endanger the final successful result. two hours, producing a good action of the bowels. After There remains the method of suture over some absorbable this there was no further vomiting of blood, although material. This has great possibilities. Its advantages are result violent with the that extremely retching persisted, that (1) complete and satisfactory suturing is more easily the fine silk used for suturing the sheath of the rectus and thoroughly carried out over its resistent surface ; (2) it at of and intestine the the wound gave way upper part the line of union from infective material until such protects on the the wound fourth day. Under chloroform protruded union is complete ; (3) it maintains patency and decreases was re-closed with silkworm-gut sutures. During these four the possibility of post-operative stricture ; and (4) when the days nutrients were retained, flatus was passed, the bowels period of its usefulness is over it disappears. But in order acted on the second day after turpentine enema, and on the to obtain the best results from it it should possess the third after calomel. The pulse-rate did not exceed 100, it should be easy of introduction ; neither did the temperature rise above 1000. The patient following qualities : first, it should be perfectly simple and require no elabothen very rapidly picked up and made an excellent recovery, secondly, rate technique ; thirdly, it should be resistant and absorbthanks to her nurses and medical attendant, and is now able ; fourthly, it should be so made that the purse-string well. perfectly sutures which encircle the ends of the gut should, as they Robson and Mr. B. G. A. in A. W. Mr. Mayo Moynihan, are tightened, approximate these ends by the mere act of their recent work Diseases of the Stomach and their when in position it should present the to of refer several cases Treatment," post-operative tightening ; fifthly, Surgical

folds of intestine which have to be united by a second line haematemesis of which four were fatal. In THE LANCET of suture in such a way as to facilitate that suturing ; and of Oct. 20th, 1900, p. 1125, three cases were reported and a sixthly, it should be of such a size and shape as to protect fair number of others have been published. The operationsthe line of suture during the period of plastic union. after which the complication has been noticed have been Examination of the bone bobbins available at the present various, as have been the causes to which the haemorrhage time shows that whilst all possess one or other of these has been attributed. The view that Mr. Mayo Robson and characters not one combines them all. The bobbins in use Mr. Moynihan take, that it is due to a reflex nervous action, at present are known by the names of the operators who would fit in well with the above case, as the severity of the have devised them. They are Jessett’s, Allingham’s, and operation and the removal of both ovaries and uterus would Robson’s. Jessett’s possesses the first, third, fifth, and sixth. no doubt upset, if any operation will, the equilibrium of the JIt is wanting in the second and fourth. Allingham’s. nervous

sympathetic

to

system.

I would add that this complication is evidently more likely occur in those whose blood coagulability is below par and

1

Abstract of

t tion

meeting

at

a paper

communicated to the British Medical Associa

Manchester, July, 1902.

506 T possesses the second, third, fourth, and sixth. It is without the first and fifth. Robson’s possesses the first, second, third, and sixth. It makes no attempt to supply the fourth and fifth. The bobbins which I bring before your notice attempt to supply them all. It is for others to say as to how far they succeed. As will be seen, they present the bevelled conical end which makes Jessett’s pattern so easy to introduce, but they are in one piece and do not require the method of

Clinical Notes: MEDICAL, SURGICAL, OBSTETRICAL,

AND

THERAPEUTICAL. REFLEX MOVEMENT OF THE AURICLE OF THE EAR. BY E. DONALDSON, L.R C.P., L.R.C.S. IREL.,

FiG. 1.

SURGEON TO LONDONDERRY

EYE, EAR,

AND THROAT HOSPITAL.

of skin reflexes have b-en described, but I am that amongst them a reflex movement of the auricle has been included. My attention was drawn to this subject by the case of a man, aged 54 years, who came under observation on May 14th, 1902, on account of suppuration in the right middle-ear with polypus. The discharge comEnterectomy. menced in the ear from some unknown cause when he was eight years of age and lasted until he was 25. He had no FIG. 2. trouble from this time till the beginning of April, 1902, when the discharge again appeared and a good deal of pain followed. The polypus was removed by means of a snare. He was very deaf in this ear, not being able to hear either a loud voice close to the ear or a watch on contact. As part of the treatment I insufflated into the meatus some powdered boric acid through an ear speculum without holding the auricle. At each puff the auricle was observed to move distinctly forwards to the extent of about one-eighth of an inch ; afterwards at different sittings I had a good number of opportunities of observing this reaction, and I found that I could produce it by blowing air from a small indiarubber bag into the auricle in Gastro-enterostomy, ileo-colostomy. the neighbourhood of the external meatus. Usually the first puff gave the best result. The movement of FIG. 3. the auricle would sometimes not occur after three or four puffs rapidly following one another. At no sitting did I fail to get the reaction. In making the observations I was careful to exclude voluntary movement, and movement that was only a part of a more general scalp movement. The patient was requested to prevent the reflex from taking place but he could not do so, and he was unable to produce the movement voluntarily. He was quite conscious of the auricle moving to the air stimulus and said that he felt it " I jumping. The left ear was normal and its auricle when blown into moved very slightly in a backward direction. Since I first noticed this reaction I have tried on several patients what movement of the auricle could be produced by blowing air from a small indiarubber bag into the auricle. In many cases no movement was observed. I have found, however, that a slight upward, backward, or forward movement is not at all uncommon. It is remarkable that a puff of air is the stimulus of producing this reflex. It is well known that capable Pylorectomy. reflexes of different parts require their own peculiar fixation to each end of the bowel which he describes.2 In stimuli-e.g., contraction of the iris is brought about the centre there is the essential portion of Allingham’s by the stimulus of light, the plantar reflex by tickling, The appropriate stimulus in the reflex now under bobbin, the double inclined plane, tightening over which &c. approximates the bowel ends, whilst the combination of consideration is found to consist of puffs of air. Is Air rus-hing into these two produces a short fold in the intestine on either it possible to give any reason for this ?’? side which is easy to unite by Lembert’s or a continuous the auricle and external meatus makes a noise and interferes with the hearing of other sounds and possibly may bring in suture, thus burying the two tied down extremities. Birds have no auricles and are not But no one form is the best for all the various operations with it foreign bodies. which are now practised upon the alimentary tract, though incommoded by the rushing of air into their external ears all forms should be only modifications of the central idea. during their flight. It is said that in long-eared bats the I present three, one for ordinary enterorrhaphy, end to end ;; auricle "is so constructed as to prevent air from rushing in while flying." These considerations appear to me to go one for ileo-colostomy or gastro-enterostomy, which, as youl will notice, is simply the first tube with the end which pro- some way towards explaining why the auricle is more jects into the colon truncated and its opening widely flared. sensitive to puffs of air than to other stimuli. But the protecting ridge and the inclined plane behind this; Londonderry. are still retained. The last form is one for use in pylorectomy. In this one end is still more widely spread out, so A CASE OF COMPOUND DISLOCATION OF THE HEAD as still more to protect the part which experience has shown OF THE HUMERUS INTO THE AXILLA. is the most likely to leak-viz., that at the junction of the BY WALTER H. BROWN, F.R.C.S. IREL, M.R.C.S. ENG. vertical with the circular line of suture in the stomach. The method of use is obvious. These bobbins have been very well made ;and decalcified for me by Messrs. Allen and THE patient, a boy, 16 years of age, was admitted into London. Hanbury of General Infirmary with the head of his left humerus Manchester. A

not

NUMBER

aware

,

.

Wigmore-street,

2

Surgical

Diseases of the Stomach and Intestines,

Leeds

p. 266.

1

Quoted by Burnett

in his Treatise

on

the Ear,

p. 29.