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POST-OPERATIVE PLASTIC SURGERY.
1303
samples of intestinal flora at various levels. The and is advised when X rays have been used on the In closing these pharyngostomes it is perforated end of the fine rubber tube swallowed by the patient is sealed in collodion sacs so that no fluid useless to slide a single flap across the opening, can enter until the end is in the situation required, having an inner raw surface exposed to contamination ; {, as determined by the length of tube paid out, con- the gap should be closed by a double layer of trolled by X rays to preclude the tube being coiled tissue which presents a lining of skin or mucous The collodion sac is burst by blowing a membrane facing inwards and of skin facing outwards. on itself. little sterile salt solution through the tube, and a ’, Skin flaps are dissected up and turned inwards to sample of intestinal contents is sucked in. The reconstruct the tube; this leaves a large raw surface tube may now be washed through with iodine and which is covered by a flap taken from the loose skin sterile salt solution and withdrawn to a higher below the horizontal ramus of the lower jaw and position in the alimentary canal where a further1 rotated into position. Four patients were shown sample is obtained. In an investigation just recorded to illustrate Mr. Colledge’s paper. In the discussion of these papers the opinion was patients with high gastric acidity were found to have low duodenal bacterial counts, whereas in those expressed that recent advances in plastic surgery with low acidity duodenal counts were high. A permitted operation on more extensive tumours than series of arthritic cases showed in the main a fermen- formerly, with the prospect of leaving the patients tative flora with Streptococcus viridans present in all in a tolerable condition. The growth of hair upon parts. The patients with enteritis and cholecystitis the inturned skin flaps was inclined to be troublehad a putrefactive intestinal flora. The bacteria some in the nose and mouth as well as in the pharynx ; in the throat, stomach, duodenum, and intestine X rays were not considered reliable in preventing this, varied greatly in the same patient. and in a recent case Mr. Colledge had had all the hair follicles epilated by diathermy before the plastic operation.
pharynx.
B
____
POST-OPERATIVE PLASTIC SURGERY. AT a meeting of the Section of Laryngology of the Royal Society of Medicine on Dec. 5th, Mr. E. Musgrave Woodman made a communication on plastic repair after operations on the upper jaw. In planning the original operation, he said, there are certain points which tend to prevent or minimise deformity, and it is an advantage when the surgeon who performs the first operation is also able to undertake any plastic procedures which may be required later. The old transverse incision below the eyelid must be relinquished, for it is often followed by unsightly baggy swelling of the lid ; Trotter’s incision through the inferior fornix of the eye may be used, but Mr. Woodman prefers to begin his incision in the eyebrow and extend it down the side of the To prevent dropping of the eye-ball, the nose. infra-orbital margin of bone should be retained if possible; failing this, the suspensory ligament should be left. Perforation of the palate is not
THE WIDAL TEST AGAIN.
THE exaggerated claims sometimes made for this test and the sweeping condemnations to which it is also subject have prompted Major J. A. Manifold, R.A.M.C., to estimate its value in more accurate terms.l In his attack upon the subject from the point of view of diagnosis of the enteric group and differential diagnosis of the paratyphoids, Dr. Manifold has a wealth of accurate data to draw upon. His first favourable circumstance lies in the existence of an ideal experimental animal-the soldier, white or native, of the Indian army who willingly reports sick within the first week of disease and thereafter submits to as many tests as are required to establish bacteriological and serological diagnosis. The results thus gathered are comparable owing to the second favourable factor which is the uniform standardised technique used in the army laboratories in India. Prof. Dreyer’s methods are followed by workers all similarly trained, and so the conditions for optimum results are fulfilled. Dr. Manifold was able to analyse 227 bacteriologically proven cases of enteric fever, of which 152 were due to B. typhosus. When on an average 4-39 tests per case had been done 64 per cent. of these would have been diagnosed and classified on their serum tests alone. If the group is subdivided, of 84 severe cases, 75 per cent. could have been diagnosed, of 68 mild cases 50 per cent., and of 24 very mild ones only 37-5 per cent. would have been detected. As an instance of these mild infections Dr. Manifold mentions patients who have been admitted to hospital for an unknown pyrexia, a blood culture made, the patient discharged as well, and readmitted a few days later when results of the culture became known. It is interesting to compare the figure for the whole group 64 per cent. with A. Pijper’s 60 per cent. in bacteriologically proven The former is the result of 4-39 tests per case, cases. the latter the finding at the first examination and of The number of course points only to enteric group. complete failures is about the same. Dr. Manifold reaches the conclusions that no serological test can
as a deformity; on the contrary, such an should be left in every case for proper inspection of the operation area. This opening is controlled by a denture, held in position by two soft rubber processes which project into the aperture. Indeed, skilled dental assistance is of great value ; a temporary plate can be made and fitted a few hours after operation, keeping the dressings in the cavity clean and enabling the patient to eat and swallow easily. A stent attached to the plate can be used to fill out the hollow left by removal of bone ; and when a large hole in the face remains, unsuitable for repair by plastic operation, a vulcanite shield can be attached to the plate to fill the gap and painted ’, to match the skin of the face. Mr. Woodman illustrated his paper by photographs showing methods of repair by means of forehead flaps and of tubegrafts taken from the chest. In a second communication Mr. Lionel Colledge dealt with the repair of pharyngeal defects after operation for removal of malignant tumours. Such openings usually occur as a complication after total laryngectomy and lateral pharyngotomy; they may be accidental, the result of wound-infection, or they may be produced replace careful, repeated bacteriological examinadeliberately, when so much of the pharyngeal wall tions ; that in average severe cases, the Widal, prachas been excised that it cannot be closed securely, tised with Dreyer’s cultures and manipulations, remains a valuable aid to differential diagnosis ; and
regarded opening
1 Thomson, A. E., Einhorn, M., and Coleman, W.: Med. Jour. and Record, Nov. 5th, p. 417.
1 Jour. R.A.M.C., June-August, 1930.
samples of intestinal flora at various levels. The and is advised when X rays have been used on the In closing these pharyngostomes it is perforated end of the fine rubber tube swallowed by the patient is sealed in collodion sacs so that no fluid useless to slide a single flap across the opening, can enter until the end is in the situation required, having an inner raw surface exposed to contamination ; {, as determined by the length of tube paid out, con- the gap should be closed by a double layer of trolled by X rays to preclude the tube being coiled tissue which presents a lining of skin or mucous The collodion sac is burst by blowing a membrane facing inwards and of skin facing outwards. on itself. little sterile salt solution through the tube, and a ’, Skin flaps are dissected up and turned inwards to sample of intestinal contents is sucked in. The reconstruct the tube; this leaves a large raw surface tube may now be washed through with iodine and which is covered by a flap taken from the loose skin sterile salt solution and withdrawn to a higher below the horizontal ramus of the lower jaw and position in the alimentary canal where a further1 rotated into position. Four patients were shown sample is obtained. In an investigation just recorded to illustrate Mr. Colledge’s paper. In the discussion of these papers the opinion was patients with high gastric acidity were found to have low duodenal bacterial counts, whereas in those expressed that recent advances in plastic surgery with low acidity duodenal counts were high. A permitted operation on more extensive tumours than series of arthritic cases showed in the main a fermen- formerly, with the prospect of leaving the patients tative flora with Streptococcus viridans present in all in a tolerable condition. The growth of hair upon parts. The patients with enteritis and cholecystitis the inturned skin flaps was inclined to be troublehad a putrefactive intestinal flora. The bacteria some in the nose and mouth as well as in the pharynx ; in the throat, stomach, duodenum, and intestine X rays were not considered reliable in preventing this, varied greatly in the same patient. and in a recent case Mr. Colledge had had all the hair follicles epilated by diathermy before the plastic operation.
pharynx.
B
____
POST-OPERATIVE PLASTIC SURGERY. AT a meeting of the Section of Laryngology of the Royal Society of Medicine on Dec. 5th, Mr. E. Musgrave Woodman made a communication on plastic repair after operations on the upper jaw. In planning the original operation, he said, there are certain points which tend to prevent or minimise deformity, and it is an advantage when the surgeon who performs the first operation is also able to undertake any plastic procedures which may be required later. The old transverse incision below the eyelid must be relinquished, for it is often followed by unsightly baggy swelling of the lid ; Trotter’s incision through the inferior fornix of the eye may be used, but Mr. Woodman prefers to begin his incision in the eyebrow and extend it down the side of the To prevent dropping of the eye-ball, the nose. infra-orbital margin of bone should be retained if possible; failing this, the suspensory ligament should be left. Perforation of the palate is not
THE WIDAL TEST AGAIN.
THE exaggerated claims sometimes made for this test and the sweeping condemnations to which it is also subject have prompted Major J. A. Manifold, R.A.M.C., to estimate its value in more accurate terms.l In his attack upon the subject from the point of view of diagnosis of the enteric group and differential diagnosis of the paratyphoids, Dr. Manifold has a wealth of accurate data to draw upon. His first favourable circumstance lies in the existence of an ideal experimental animal-the soldier, white or native, of the Indian army who willingly reports sick within the first week of disease and thereafter submits to as many tests as are required to establish bacteriological and serological diagnosis. The results thus gathered are comparable owing to the second favourable factor which is the uniform standardised technique used in the army laboratories in India. Prof. Dreyer’s methods are followed by workers all similarly trained, and so the conditions for optimum results are fulfilled. Dr. Manifold was able to analyse 227 bacteriologically proven cases of enteric fever, of which 152 were due to B. typhosus. When on an average 4-39 tests per case had been done 64 per cent. of these would have been diagnosed and classified on their serum tests alone. If the group is subdivided, of 84 severe cases, 75 per cent. could have been diagnosed, of 68 mild cases 50 per cent., and of 24 very mild ones only 37-5 per cent. would have been detected. As an instance of these mild infections Dr. Manifold mentions patients who have been admitted to hospital for an unknown pyrexia, a blood culture made, the patient discharged as well, and readmitted a few days later when results of the culture became known. It is interesting to compare the figure for the whole group 64 per cent. with A. Pijper’s 60 per cent. in bacteriologically proven The former is the result of 4-39 tests per case, cases. the latter the finding at the first examination and of The number of course points only to enteric group. complete failures is about the same. Dr. Manifold reaches the conclusions that no serological test can
as a deformity; on the contrary, such an should be left in every case for proper inspection of the operation area. This opening is controlled by a denture, held in position by two soft rubber processes which project into the aperture. Indeed, skilled dental assistance is of great value ; a temporary plate can be made and fitted a few hours after operation, keeping the dressings in the cavity clean and enabling the patient to eat and swallow easily. A stent attached to the plate can be used to fill out the hollow left by removal of bone ; and when a large hole in the face remains, unsuitable for repair by plastic operation, a vulcanite shield can be attached to the plate to fill the gap and painted ’, to match the skin of the face. Mr. Woodman illustrated his paper by photographs showing methods of repair by means of forehead flaps and of tubegrafts taken from the chest. In a second communication Mr. Lionel Colledge dealt with the repair of pharyngeal defects after operation for removal of malignant tumours. Such openings usually occur as a complication after total laryngectomy and lateral pharyngotomy; they may be accidental, the result of wound-infection, or they may be produced replace careful, repeated bacteriological examinadeliberately, when so much of the pharyngeal wall tions ; that in average severe cases, the Widal, prachas been excised that it cannot be closed securely, tised with Dreyer’s cultures and manipulations, remains a valuable aid to differential diagnosis ; and
regarded opening
1 Thomson, A. E., Einhorn, M., and Coleman, W.: Med. Jour. and Record, Nov. 5th, p. 417.
1 Jour. R.A.M.C., June-August, 1930.