Eleven cases : roentgenographic and operative findings / by A. Judson Quimby and William Seaman Bainbridge.

  • Quimby, A. Judson (Adoniram Judson), 1875-
Date:
1914
Catalogue details

Licence: In copyright

Credit: Eleven cases : roentgenographic and operative findings / by A. Judson Quimby and William Seaman Bainbridge. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    meal, if it contains sufficient bismuth; other- wise, this jDortion is also examined after the second meal. When examining the terminal ileum, it should be sufficiently isolated from other ileal coils to give it a clear field, and if this is impossible, we are forced to wait until the other coils of the intestines are empty. In manipulation of the ileum the first act is to push the cecum up, then apply pressure between the cecum and ileum and endeavor to separate them; the terminal ileum is then moved from side to side and its motility determined. At the same time several sections may be manipulated upward and downward; pressure is then applied just above the cecum to force it downward to the position assumed while in the erect posi- tion; this will kink the ileum, if an ileal band or contracted mesentery exists close to the ileo-cecal valve. Frequently ileal bands in- volve the parts adjacent to the pelvic brim; these can be determined by manipulation of the ileum at this point. A determination of the appendix of neces- sity is best made when this organ is filled with bismuth, but frequently in a thin sub- ject, we may palpate it when but a small portion of the appendix is visible. The ap- pendix very frequently will not fill while the ileum retains sufficient bismuth to out- line it. My experience has taught me that the appendix is most apt to fill after a large enema has been given, and appendices that do not appear during the stasis test are most always found twenty-four hours after the administration of the enema to contain a surprising quantity of bismuth; this has enabled me frequently to locate an appendix that would ordinarily escape in- spection. The explanation I have for this, is that the organ was filled with feces that prevented the entrance of the bismuth. An enema dislodges this, and permits the en- trance of the bismuth that has already been administered by mouth at the same time the enema was given. Of a large number of cases that are ex- amined for the appendix alone, I never failed to find some portion of it filled with bismuth. One case, which at operation was found to have almost the entire canal obliter- ated, when inspected by the fluoroscope pre- vious to the operation contained bismuth in about one-half inch of its proximal portion. The examination of the appendix, cecum and terminal ileum involves careful man- ipulation, but with a trained hand this can be done in a very few seconds. I am usually able to do this within five seconds, but to be sure, this does not mean that an entire determination is made in this time, but the portion of intestine that is examined at each visit is that part which is best filled, and we need not examine all these sections each time the patient is on the table. The mobility of the cecum is readily determined, unless lodged in the pelvis, but by careful watching over several days, we may make it unnec- essary to attempt to dislodge the cecum from the pelvis. My usual practice is to allow sufficient time for the cecum to empty and contract, which will draw it up out of the pelvis, or the administration of an enema may distend the rectum and push it upward. Digital pressure from below may be em- ployed when justifiable, in the endeavor to ascertain whether the cecum may be dis- lodged or not. With regard to the determination of the cause of colonic obstruction, manipulation under the fluoroscope during the passage of the bismuth meal is the most valuable pro- cedure; this is superior to manipulation fol- lowing the administration of an enema, pro- viding the various sections of the colon re- tain sufficient amounts at the time of the ex- aminations. Ingested bismuth is usually in the more solid state in the colon than the enema, therefore much better manipulation can be followed. Attempts to determine ad- hesions when the colon is distended by the very fluid enema, in addition to the added rigidity of the abdomen from abdominal distension, render it very deceptive, and should not be given much credit. Examination for bands, adhesions, and membranes involving the ascending colon, as well as other sections of this portion of