thrusting a scalpel or an instrument such as a large haemostat forceps throughthe abdo- minal or chest walls. An opening thus ha~ving been made, the drainage ...
1300
21 May 1966
Correspondence
We are at present engaged on the histological examination of the brains of chimpanzees which were inoculated with kuru material by Dr. Gajdusek and his colleagues.-We are, etc.,
developed a coliform septicaemia.-We are, etc., B. M. GREENWOOD. E. B. LARBI.
Maudsley Hospital, London S. E. 5.
ELISABETH BECK.
University College Hospital,
Ibadan, Nigeria.
PETER DANIEL.
REFERENCES
Bertrand, I., Carr6, H., and Lucam, P., Ann. Anat. path., 1937, 14, 565. 2 Beck, E., Daniel, P. M., and Parry, H. B., Brain, 1964, 87, 153. 3- - and Gaidusek, D. C., Proc. Vth Int. Congr. Neuropath. Zurich (Excerpta Med.), 1966, in press.
Ulcerative Colitis in Africans SIR,-We were interested to read the report of Dr. J. R. Billinghurst and Dr. J. M. Welchman (22 January, p. 211) on the occurrence of ulcerative colitis among the Baganda, as we have recently seen a West African patient who appeared to have this disease. A 60-year-old Yoruba farmer was admited to hospital under the care of Professor T. W. G. Kinnear with a three-month history of weight loss and bloody diarrhoea. He was a wasted anaemic old man with oedema of the ankles and patchy depigmentation of the skin. No abnormality was found on examination of the abdomen. Laboratory investigations gave the following results: haemoglobin 5.8 g./l0O ml., blood urea 14 mg./l00 ml., serum potassium 2.8 mEq/L., total plasma proteins 4.1 g./100 ml. and normal liver function tests. Repeated stool examinations showed ova of ascaris and hookworm and a few strongyloides larvae but no active or cystic forms of Entamoeba histolytica. No pathogenic organisms were isolated on stool culture. The lining of the bowel was found to be reddened and inflamed at sigmoidoscopy. No amoebae were seen in a smear taken from the bowel wall. A barium enema showed loss of haustration and increased rigidity throughout the length of the transverse and descending colon. A week after admission the patient suddenly developed peripheral circulatory collapse. A chest x-ray and an electrocardiogram showed no evidence of pulmonary or myocardial infarction. The serum potassium had risen with treatment to 3.6 mEq/L. Intravenous infusion and blood transfusion restored the blood pressure to normal, but the patient gradually passed into coma and died. At post-mortem (Dr. N. Ikoku) no abnormality was found to account for the patient's sudden death. The whole of the colon was fibrotic. The mucosa was inflamed throughout its length and over large areas had been completely destroyed. Typical amoebic ulcers were not seen. The small bowel and the liver were macroscopically normal. Microscopy showed extensive destruction of the mucosa of the large bowel with infiltration of the submucosa by -hronic inflammatory cells. A few chronic nflammatory cells were seen in the portal tracts f the liver. The high incidence of amoebiasis in this irea makes this the most likely diagnosis in any patient presenting with colitis. In this -ase no evidence of amoebiasis was found and :he radiological and pathological features Nere very suggestive of ulcerative colitis. The
Pathological findings suggested large bowel
lisease of long duration. The patient gave history of diarrhoea for only three months, )ut his general appearance and the degree of iypoproteinaemia suggested that he had been 11 for longer than he admitted. The cause Af the patient's sudden death was never estabished; we wonder whether he may have i
New Drainage-tube Introducer SIR,-On completing an operation by inserting drains into the peritoneal or pleural cavities most surgeons avoid bringing out the drainage device, either a tube, corrugated tissue, or Penrose drain, via the main wound. To do so allegedly interferes with wound healing and predisposes to wound dehiscence or an incisional hernia subsequently developing. To avoid such complications it is customary to exteriorize drainage devices via a separate "stab" incision made in the parietes at some distance from the main wound and placed to facilitate drainage. Such an incision is appropriately termed a stab incision, as it is commonly carried out by thrusting a scalpel or an instrument such as a large haemostat forceps through the abdominal or chest walls. An opening thus ha~ving been made, the drainage device is grasped by a pair of forceps introduced through the stab incision and withdrawn to the exterior. It is my experience that the methods of performing this stab incision, as usually carried out with a scalpel or a haemostat, are not wholly satisfactory. A scalpel-thrust not infrequently severs blood-vessels in the parietes, which can give rise to troublesome bleeding, and it has been my humiliating experience on one occasion to have to return a patient to the operating theatre in order to arrest haemorrhage from such a stab incision. Use of a scalpel, however, has the merit of making an opening rapidly, easily, and without the necessity of using force. It is otherwise on occasions when using the alternative method of pushing a blunt instrument through the abdominal or chest walls. Having made a small preliminary knife cut in the skin, penetration of the parietal wall is accomplished by means of the blunt forceps, which are thus available and in position to
M:ICAL JOURNAL grasp the drainage device for withdrawing to the exterior. This technique avoids division of blood-vessels and the possibility of causing annoying bleeding. However, in a patient with a thick parietal wall and firm unyielding tissues considerable force may have to be applied to the haemostat before penetration is completed, and there is always the nagging anxiety while pushing hard that penetration may finally be accomplished suddenly and before the advance of the instrument can be controlled, damage to underlying structures may be occasioned. In order to avoid the drawback of both of these common methods of performing stab incisions a simple instrument has been devised which essentially is a modification of a large straight haemostat and which I feel merits inclusion among the stock instruments of laparotomy and thoracotomy. The main features of the instrument are as follows: it has a blunt pointed tip; the working end of the instrument is tapered and is ground to bear four blunt edges at the tip, which is quadrilateral in cross-section, changing to six blunt edges and a hexagonal cross-section in its main portion. Functionally the instrument is designed to facilitate penetration with minimal potential for causing bleeding. Its action is to penetrate, shear through, and dilate up a track as it is being inserted; without the necessity of using force. Its point and edges are too blunt to incise, and have the property of brushing the tissues aside. Before it is used the skin at the site of the stab is first divided with a scalpel as the instrument will not penetrate the skin unaided. The instrument, having emerged into the serous cavity, is then used as a forceps to grasp the drainage tube or tissue and withdraw it through the stab opening. The first prototype of this drainage tube introducer was made by Chas. F. Thackray Ltd. Purther developments were carried out with the courteous technical cooperation of Maior J. D. McWorth, R.E.M.E., 55 Area Workshops, Singapore. -I am, etc., University of Singapore. L. F. TINCKLER.
Tortion of Testis after Eversion of Sac of Vaginal Hydrocele SIR,-It is surprising that trouble does not arise from torsion of the testicle after it has been replaced in the scrotum following operations for hydrocele and hernia, etc. I should like to describe a case of torsion of the testicle following operation for vaginal hydrocele. An extensive search of the literature has not revealed any other case having been reported. A. B., a 59-year-old male, had a Bassinni's repair done for a direct right inguinal hernia in 1956. Two years later a swelling appeared on the right side of the scrotum, which had gradually increased in size. On examination it was found to be a vaginal hydrocele. At operation on 22 January 1965 under general anaesthesia a moderate-sized sac of the right tunica vaginalis was everted using catgut. Interrupted catgut stitches were placed in the dartos muscle and skin. The wound was not drained. Fifty-two hours later the patient developed sudden severe pain in the right testicle while straining at defaecation. On examination the testicles were drawn up, swollen, and very tender.
