A RACK FOR FACILITATING THE HANDLING OF SMALL DEEP SKIN GRAFTS
Journal of the American Medical Association
Volvulus is one of the rarer conditions of the intestinal tract which produces ileus. The case herein described is of unusual interest because of the nature of the onset and the portion of the intestine involved and its position. E. S., a man, aged 62 years, worked for forty years in cotton mills as operator and later as overseer. He has had hemorrhoids and chronic bronchitis for forty-five years, but rarely consulted a physician for these conditions and never for any other. In December, 1915,
... In December, 1915, while digging a path in the snow, he had a sudden attack of pain in the abdomen which disappeared in a few moments. Later, tenderness developed, followed by pain and vomiting. A diagnosis of appendicitis was made. Operation was advised but refused. Two hypodermics of morphin relieved the pain, and after two days' repeated use of high enemas, the bowels began to move. The patient was in bed most of the time for six months thereafter with a marked obstipation, and usually with distention and pain on the left side. He was told that this was due to a "twist of the gut." Since that time he has had more or less tenderness in the abdomen, with increased formation of gas in the stomach and a gradual loss of weight. The present disturbance began June 8. The patient worked in his garden until 10 a. m. The sun was bright and he stopped work because he felt dizzy. Half an hour later he had a copious bowel movement and shortly afterward began to have a sense of discomfort in the abdomen. This increased gradually until 4 p. m., when he went to bed, thereafter spending most of his time in a modified knee-chest position, the assumption of which gave him some relief. Although the same medication was instituted which relieved his first attack, that is, paregoric and high enemas, without hypodermics, however, at midnight the pain became intense and the patient began to vomit. The first enema was colored and brought away a little gas, but the others had no effect. I saw the patient at 2 a. m., when the pulse rate was 70, respiration 28, and temperature 99.5. There was a soft fluctuating mass distending the abdomen on the left side, tender on pressure and tympanitic. A diagnosis of intestinal obstruction was made, probably due to volvulus. Operation was advised, and refused, because of recovery eighteen months before. Threeeighths grain of morphin by hypodermic gave some relief. I saw him again at 8 a. m. and 2 p. m. The condition was unchanged, the patient having dozed at intervals since the hypodermic. Operation was still refused. At 2 p. m. a second hypodermic of one-eighth grain of morphin was given and the family was advised to get another physician in consultation unless consent was given for operation. At 6 p. m. I was asked to come in a hurry as the patient had vomited fecal material. The tumor was still present, pulse 110, respiration 34, temperature 101. Consent was • given for operation. At 7:30 p. m. the patient was opened in the midline. A distended loop of large intestine filled the left side of the abdomen. This was delivered with difficulty and proved to be the cecum, about 15 inches long and 8 inches in diameter. The tip of the appendix, about 6 inches long, was in a mass of adhesions attached to the sacral prominence in the midline, and apparently around this point as a fulcrum the cecum. with its tremenduously elongated mesentery, had made a half turn and lodged on the left side. There was no gangrenous tissue from the strangulation. By a simple twist the cecum fell into its normal position and its contents could be forced into the transverse colon. As the patient was moribund the appendix was hurriedly removed, a small reef was made in the mesentery, and the abdominal incision rapidly closed. The patient's life hung in the balance for five hours, since which time there has been progressive recovery. This instrument has been devised for exploring different regions of the brain and also as a means of instituting permanent ventricular drainage in cases of internal hydrocephalus, on the service of Dr. William Sharpe. It consists of a dull-pointed ventricular puncture needle, 15 cm. long, with two eyelet openings near the end; a forked stylet 15 cm. long; a casing 6 cm. long; and a probe 15 cm. long; all are graduated in centimeters. When the ventricular cavity is entered, the stylet is removed, allowing the fluid to escape. If a permanent drainage is desired, the depth of the cavity is ascertained, Stylet 3 is removed, and the outer casing, 1, 6 cm. long, and also graduated in centimeters, is inserted over the puncture needle, 2, to the desired depth. There the casing is held in the proper position by means of the handle, and the puncture needle is now removed, leaving the casing, 1, in situ; a forked stylet, 4, graduated in centimeters, and 15 cm. long, carries the linen strands to the desired depth in the ventricles, and is held in place while the casing, 1, is withdrawn. Then the stylet, 4, holding the linen strands, 5, in the proper place and depth, is removed, and the linen strands are brought out through the cerebral cortex, the temporal muscle and fascia under the skin. The linen strands are very slowly absorbed (in from five to seven months), and in the meantime this artificial cortical channel is lined with endothelium about the linen strands, and permanent drainaee Details of apparatus for intraventricular drainage. of the cerebrospinal fluid is thereby obtained. With this drainage apparatus, a minimum amount of trauma is done to the brain tissue, and the drainage material is left in situ at the point desired in the ventricles. The appliance here illustrated is for facilitating the handling of small deep skin grafts. When two or more are working on a large wound, the grafts are often cut faster than they can be applied. As a rule there is no convenient location to stack the artery clamps holding needles and grafts. In consequence an instrument is often upset or slips; the graft is brushed off, and is either lost, or much time is wasted in trying to pick it up. In order to eliminate this inconvenience. I devised this slotted metal rack to hold the clamps. The rack is made of 18 gage sheet copper, so bent that the end view shows the form of a trapezium. The longest side of this figure is used as the base, and to facilitate cleaning is open, except for three strips which are necessary to brace it. The twelve slots are made on the side opposite the base, and each is wide enough to admit the ordinary Halsted artery clamp. The measurements are: base, 9 cm. long; surface carrying slots, 6.5 cm. long; sides, S.S and 6.S cm. long. The full length of the rack is IS cm. Longer racks may be made, but the size described is convenient for ordinary use.