a semi-annual return for treatment will test the possibilities of further gain and prevent loss. The actual increase of hearing thus gained may be small, and yet give the patient many times as much as he had before; it may also check the downward progress of the affection, and confer an inestimable benefit, as well worthy of our best efforts as many a brilliant success in more favorable fields. A NEW FORCEPS FOR INTESTINAL ANASTOMOSIS.1 THE author gave a demonstration of intestinal anastomosis by a new forceps, a full description of which already appeared in the Philadelphia Medical Journal, June 9, 1898. He stated that other appliances used in suturing are unsurgical in so far as they have to be left within the intestine. He thought if some appliance could be devised that would EA YARNALL CO. PHILA. Ac enable very accurate suturing of the intes tine, and not leave within it a foreign body, it would be a step forward in surgery. The instrument exhibited by Dr. Laplace consists of two parts which are really hemostatic forceps curved into a semicircle on each side. When held together by means of a clasp, they open as two rings. They are opened within the intestine and serve the same purpose of support that Senn's ring, or any other ring that has been devised, bringing serous membrane to serous membrane. curate suturing is the operation of the present. Therefore, if these forceps are within the gut, and sutures are applied, as they would be with the help of Senn's rings, it follows that sutures are introduced all around, except where the forceps penetrate the parts that were sutured. The suturing being done, the forceps are released by loosening the clasps, and then pulling the forceps out of the small opening, first one, then the other, when the operation is finished by a stitch or two. Dr. Laplace has had five sizes of forceps made to suit dif ferent calibers of gut. These forceps will enable the performance not only of end-toend anastomosis, but also of lateral anastomosis. He first illustrated the efficiency of the forceps by doing a gastro-enterostomy upon some post-mortem viscera, stating that to do the operation only a knife, the forceps, a needle and thread are needed. He did the operation upon a very small stomach, making two openings: one in the stomach, and one in the gut, and, opening the forceps, introduced one blade into the intestine, then put the other blade into the stomach, and held the two blades apart, and then closed them. Thus the cut intestine and stomach were held all around while he sutured. He uses a continuous suture, but any suture may be employed. The forceps have lifting handles made to raise the intestine up, and affords support as well as a broad surface to work with. Having united the stomach and intestine as far as he desired he easily removed the forceps, by removing the clasp, then one forceps was loosened and drawn out with a semicircular motion, and EA YARNALL CO. PHILA. then the other was removed in the same way; finally one more stitch was applied to close the opening through which the forceps were removed. The stitches were much more regular than could possibly have been applied without a support and the support did no harm to the intestine. Mechanical means were only used to make the manual 1 Demonstrated before the Philadelphia County Medical Society, November 23, 1898. the suturing is done, the instrument is loosed and withdrawn; one more suture is applied at the point where the instrument penetrated. This makes a very good stump, and is very expeditious. The smallest size forceps (No. 1) is used for uniting the gallbladder with the intestine. The other sizes are for use upon patients of various ages. Aside from numerous operations upon dogs, this method has already been applied to the living, and has been found to answer all requirements. BOOKS RECEIVED. MANUAL OF THE DISEASES OF CHILDREN. By John Madison Taylor, A.M., M.D., and Wm. H. Wells, M.D. Illustrated. 8vo, pp. 743. Philadelphia: P. Blakiston's Son & Co. 1898. A COMPEND OF OBSTETRICS. Especially Adapted to the Use of Medical Students and Physicians. By Henry G. Landis, A.M., M.D. Revised and Edited by William H. Wells, M.D. Sixth Edition. Illustrated. 12mo, pp. 182. Philadelphia: P. Blakiston's Son & Co. 1898. Treatment of Tuberculous Adenitis of the Neck by the Roentgen Rays.-Hendrix (La Policlinique, May, 1898) gets encouraging results from radiography in scrofulous glands. When the latter are fused together, and before caseation has taken place, the rays seem to isolate them-they become mobile, smaller and firmer. If, however, caseation has begun, the rays have a distinctly irritating effect, and will aggravate the disease, and are contraindicated. The author seems to believe that the rays destroy the bacillus, but apparently made no attempt to verify his theory by excision. Record of the Philadelphia County Medical Society Stated Meetings for Scientific Work.-Second and Fourth Wednesdays of each month, except Business Meetings.-Third Wednesday of January, April, June and October. Members desiring to read papers or present specimens at the Stated Meetings are requested to com- Copies of all papers read before the Society, or, by previous arrangement with the Publica- Members who express the wish in good time will be provided by the Editor (Dr. Spellissy, 108 S. The Mutual Aid Association of the Philadelphia County Medical Society was incorpo- Change of Address should be promptly communicated to the Secretary, Dr. John Lindsay, 340 S. Fifteenth Street, and to the Assistant Secretary, Dr. Elwood R. Kirby, 1202 Spruce Street. The next meeting of the Philadelphia County Medical Society will be held on Wednesday evening, December 14, 1898. Members of the Philadelphia County Medical Society are requested to send their subscription for the Jubilee Dinner to Dr. Jas. Tyson, Chairman, 1506 Spruce Street. Stated Meeting, November 23, 1898. S. SOLIS COHEN, M.D., First Vice-President, in the chair. DR. E. BRUCE WENNER presented a specimen of A PIECE OF OMENTUM REMOVED FROM A WOMAN 62 YEARS OF AGE. It was the only part of her peritoneum that had not undergone fatty degeneration. The woman died from obstruction of the bowels produced by cancer of the head of the pancreas and of the whole head of the duodenum. All of the fiber of the pancreas that could be found was that existing in the exhibited specimen. DR. ERNEST LAPLACE demonstrated A NEW FORCEPS FOR INTESTINAL ANASTOMOSIS. (See page 552.) DISCUSSION. DR. J. CHALMERS DACOSTA, who had previously seen the utility of these forceps demonstrated by Dr. Laplace on the intestines of a cadaver and on those of a living man, said that, to him, the instrument appeared to even greater advantage when used upon the thicker intestine of the living than it did when employed on the thinner intestine of the dead. The expediency of The expediency of using a mechanical device in suturing had been largely debated and is still unsettled. The trend of surgical opinion is that what ever disadvantages the use of a mechanical device may possess, it greatly facilitates the application of sutures. The instrument of Dr. Laplace affords all the advantages to be gained from such mechanical devices as the Murphy button, bone-plates, etc., and yet it is free from their disadvantages, because the operator having enjoyed all the benefit of the forceps removes them, while such devices as the Murphy button must remain in the intestine, and be a cause of anxiety till they have separated and been discharged. A special virtue of the forceps is that they render it easy to place the sutures with mathematical certainty at the required distances. This is so because the rim of the instrument renders it extremely easy to catch the serous coat, and because the suture line not only is held in perfect and firm apposition, but can be kept under perfect control by the handles. The instrument is simple, and, unlike many other devices, may be successful not only in the hands of its originator, but of all who use it. It is destined to replace the mechanical aids of many other methods. DR. ORVILLE HORWITZ said he had listened with a great deal of pleasure to the instructive demonstration of Dr. Laplace and felt sure that his ingenious instrument will prove to be one of the greatest advances made in intestinal surgery in years. The objection to the catgut ring, bone-plates, bone-bobbins, and similar mechanical devices, is that in their employment much valuable time is consumed and a foreign body is left in the intestinal canal. The Murphy button combines speed with a certain amount of safety; no surgeon who inserts the button is without anxiety until it has been voided through the rectum. The rubber cylinder is a step in advance of either the rings or the bobbins. What Halsted claims for the cylinder is justifiable: the operator can dispense with clamps, the vermicular motion of the bowel is arrested, the adjust ment of two ends of intestine, of unequal size, is facilitated, and finally, valuable time is saved by its employment. The objection to the rubber cylinder is that it is a complicated device; often difficult to manage; its proper adjustment frequently requiring a good deal of time. Until the introduction, to the profession, of Laplace's anastomosis forceps, it was superior to any other mechanical contrivance devised to facilitate intestinal anastomosis, with the exception of the Murphy button, which was to be preferred when time was an object. The anastomosis forceps will be found to be superior to the cylinder. The former is not so complicated, is easier of adjustment, and the operation can be performed with as much speed as in cases where the Murphy button has been used. Personal observation of the practical application of the forceps, in the hands of Dr. Laplace, at the Medico-Chirurgical Hospital, convinced Dr. Horwitz that this instrument is far superior to any contrivance that has been heretofore suggested or employed; and when the profession becomes familiar with the instrument, it will supersede any form of mechanical device at present employed in intestinal surgery. DR. EDWARD MARTIN greeted the forceps as an admirable mechanical device that will improve intestinal technic. He applauded the modest manner in which Dr. Laplace had presented his instrument and predicted that since it had done so well on the dead it would be much more efficient when used upon the living. It facilitates the operation, it expedites it, and finally makes the sutures very much more accurate. Moreover, the forceps are simple in construction. Yet facility in handling them should be thoroughly acquired, as the management of any new instrument should be, before em ploying it on a patient. This experience may be gained on the dog, but is preferably obtained upon the intestines of the recently dead. The technic of this instrument can be acquired much more rapidly than that of the ordinary intestinal suture, and an added advantage not mentioned by Dr. Laplace is that the metal instrument will guide the surgeon in suturing. Improvements short of being revolutionary in the field of surgical appliances rarely have a widespread adoption. This is to be deprecated, and while Dr. Laplace does not claim for this instrument any revolutionizing power, still anyone who has attempted suturing through a thick abdominal wall with a short mesentery will probably supply himself with this forceps. DR. HEARN expressed his belief that surgeons who opposed mechanical aid in intestinal anastomosis will be glad to use Dr. Laplace's forceps. He advocates the use of the Murphy button where hurry is imperative to combat shock or long exposure, but recognizes that the sequences of the Murphy button are sometimes unpleasant, e. g., sloughing. Dr. Laplace's instrument is ideal. DR. A. J. DOWNES was impressed by the ease with which Dr. Laplace used the forceps. He said that intestinal anastomosis only attained success with the advent of the Murphy button, the objections to which are well-known. From experimentation on animals, Dr. Downes was convinced, until very recently, that the ideal method of doing anastamosis was by the use of inflatable rubber bulbs or cylinders. But seeing Dr. Laplace use his forceps at a private demonstration about two weeks before, he thought that forceps on this principle would prove the instrument of the future. He considered the instrument as devised by Dr. Laplace too complicated and had a simpler one made. Dr. Laplace's forceps is formed of two complete forceps, the bowel blades of each forming half a circle, or half an ellipse, the two locked together forming the bowel blades, circular for end-to-end union, elliptical for side-to-side union. His forceps contain five separable parts. Dr. Downes' instrument for end-to-end anastamosis is a single-locking forceps, the bowel blade end forming a fenestrated circle with a very small segment left open for the easy withdrawal after use. The blade for the side-to-side union forms an unbroken fenestrated ellipse, removable from half an inch of unsutured bowel. These forceps are introduced practically as by Dr. Laplace. Their removal is simpler. In removing the end-to-end forceps, the bowel, after suture, rolls into the hollow of the blades through the small open segment as the blades roll out of the bowel. Rotation of a quarter of a circle in the line of suture removes the forceps, after which one suture may close the bowel. In the side-to-side union Dr. Downes leaves half an inch unsutured, removes forceps by direct traction, and completes his suture. These simplified forceps owe their birth to having seen Dr. Laplace use his. No originality is claimed, other than the reduction to simplicity of what should prove a valuable, practical, and rapid method in anastomosis. DR. RODMAN, who had seen several demonstrations by Dr. Laplace of his forceps, had been each time most favorably impressed by the instrument. Like Dr. DaCosta, he thought it the best of the mechanical aids that have been used in intestinal work, and predicted that it will displace all others. It is not quite so rapid a method as that of the Murphy button, but is free from the latter's many objections. Use of these forceps will not be attended by the same danger of pressure necrosis, of leaking from an intestine, of septic peritonitis, of intestinal obstruction, and of the lodgment of a foreign body in the stomach as has been reported by Willy Meyer and many others who have used the button, and therefore the Laplace is an ideal method. DR. M. PRICE pronounced the instrument perfect in its accomplishment of anastomosis, and said it would displace other devices. Although the Murphy button is the most rapid method, it cannot be any more accurate than the Laplace forceps, and has an exceedingly dangerous complication when a small intestine is fastened by it to the stomach, because there are two ends to the intestine, into either one of which the button may drop. If the case is cancerous, or of a similar character, a button that has gone the wrong way will stay and ulcerate, and the complication ends the patient's life. This is also true in the anastomosis of a small intestine to a large one, in order to switch off a cancerous portion, and complete the lumen of the bowel. The forceps fulfils the indications in another way, and is absolutely clean. No matter how expert an assistant, it is almost impossible in performing intestinal anastomosis by former methods to keep feces and gas from extravasating. The forceps keep the parts clean, and also in apposition throughout the suturing, which it much facilitates. End-to-end union in bowel of the same caliber it accomplishes with perfect ease, but that is not the kind of bowel usually met by Dr. Price. His experience includes 12 cases of obstruction of the bowel from cancer. He has seen a colon, larger than his arm, contracted in another portion to the size of his thumb. This case was operated upon a week before Dr. Abbe read his paper upon intestinal anastomosis. When an attempt was made to close the artificial anus established, the spur was cut away. But as union did not result, the bowel was torn loose from its adhesions to the abdominal wall, and was closed in with two rings, one large ring being put at the center of the spur. The bowel was replaced, and the result was perfect. The woman lived four years, and then died of cancer. anastomosis, the instrument of Dr. Laplace will be of great help; with a little ingenuity, it should meet all the complications to be dealt with. It is, probably, the best mechanical appliance yet seen in intestinal surgery. In DR. LAPLACE expressed his thanks to the critics for their kind opinions of his instrument and said that if it deserves one-half of what had been said he would be very well satisfied with it. The instrument shown by Dr. Downes was similar to one manufactured for Dr. Laplace about a year and a half ago. Dr. McKenna called the attention of Dr. Laplace to such an instrument, suggesting that it would be as serviceable, but far simpler. Experience proved the contrary. In reply to the objection of Dr. Price that the instrument may be less efficient in uniting the small gut to a possibly large gut, Dr. Laplace said if any difficulty arose the blame should attach to the operator rather than to the instrument, and, moreover, the method of lateral anastomosis with invagination of the ends of the gut could always be employed, which had been shown to be well controlled by the instru ment. |