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there was no demand for an increased blood-supply,and effort was limited, not by pain, but by sensationsprovoked by a diminished output of blood from theheart.heart.

Pain not in Itself Dangerous. IGreat as the distress is which pain produces, pain

itself is in no sense a dangerous symptom. It may beassociated with conditions which are dangerous, butsuch dangers are not rendered less dangerous by easingthe pain. Indeed, it often is a beneficent agent, indirecting attention to the presence of a morbid condi-tion, and more especially in warning that the persist-ence of a particular condition is harmful. It is inthis latter sense that pain is beneficent, and used inconditions like angina pectoris it forms one of the mosthelpful indications for preserving the efficiency of theheart. It is manifest that .the amount of work thedamaged heart can perform is limited, and theindications for treatment are to save the heart musclefrom over-exertion. The measure of the amount ofwork is found in what can be done without distress.It is well recognised that, before pain arises, there are.faint signs experienced which indicate that withpersistence pain will be induced, so that taken as asignal to desist, the individual then knows whatamount of effort it is safe for him to undertake. Inthis way many people are able to pursue even laboriousoccupations with no discomfort and no danger.To remove this valuable indicator in the present

state of our knowledge is, to my mind, extremelyhazardous and bad practice. When a better knowledgeis acquired it may be found of value in some instances,but so far as I can see there are no indications whichwould enable suitable cases to be recognised. I havecarefully studied the published records of cases

operated upon, and these records show no conscious-ness of that division of angina into primary, withvarying degrees of morbid changes, and secondary,with no affection of the heart. Moreover, the recordsboth before and after operation are given so imper-fectly that no clear conception of the nature of thecondition can be ascertained, except those who diedin consequence of the operation.

It must be remembered that, though pain may berelieved, the patient is not " cured," nor is the progressof the disease stayed. As the vast majority of patientslive for many years after the first appearance of anginapectoris, the fact that a patient is free from pain formonths or years is not evidence that his conditionis improved. Such patients as have been operatedupon and have recovered from the operation wouldafford the opportunity for investigation, not only ofthe results of the section of nerves, but of the responseof the heart to effort, to find out, not only how the

Iheart’s movements are affected, but what are thesensations which warn the patient of the heart’s Iexhaustion. So far the published reports fail to

Iafford this information. INeed for Be-Investigation of Cardiac Nerves. I

The attempt to find a reason for employing surgeryin the treatment of angina pectoris has revealed thatvery little of practical value is known about thefunctions of the vagus and sympathetic nerves,and in consequence plans are being formed for thereinvestigation of these nerves. Before such a

laudable enterprise be entered upon it would be wellfor the investigators to review all the work that hasbeen done on this subject and to study the reasonswhy so little is still known. It will be found that agreat number of experimental observations have beenmade and certain reactions have been detected, butthe interpretations of these reactions are imperfect andunreliable. Thus, an increase or a decrease in the rateof the heart may have been recorded, but it is notknown what structures were involved in bringingabout these changes in rate. The interpretation whichholds the field to-day was made at a time when thepresence of- the conducting system was not evensuspected. No movement of the heart can take placewithout the participation of this system, and so little

is known of this system that its study can scarcely beconsidered to be begun.Such observations that have been made on these

nerves have been almost entirely limited to theefferent nerves. In clinical medicine, and especiallyin dealing with angina pectoris, it is the part playedby the afferent nerves that has to be known, andexcept the results of some crude badly interpretedexperim.ents, nothing is known of the afferent system.of nerves. The reason for this is that the afferentsystem of nerves of the whole body are beyond therange of experimental observation. The most impor-tant functional part of the afferent nerve is situated inthe fibrils at its peripheral distribution-in the skin,and in the substance of the organs-and it is themanner in which these peripheral fibrils are stimulatedwhich requires to be found out. In experiment whenthe nerve is cut, this essential part is cut off andcannot be replaced by electrical stimulation of eithercut end. It would be as reasonable to investigatesight by cutting off the eyeball and stimulating thestump of the optic nerve as to investigate the functionof an afferent nerve by cutting it and stimulating itsstump.The clinical evidence of the part played by the

afferent nerves is abundant. The whole series ofphenomena in angina pectoris are but evidences oftheir activity-the pain, the constriction of the chest,the flow of saliva, and other signs are all evidencesthat impulses have arisen in the heart and have beentransmitted to the central nervous system. So little,indeed, is known that the source and nature of theseimpulses is still a matter of controversy.

Such matters as these must be considered by would-be investigators, as well as the reason for the defectiveknowledge which continues in spite of all attempts tofind out the function of these nerves. It is likely thatit will be found that some concept other than thosewhich have guided research in the past must beemployed, and it may come to pass that such an

investigation can only be carried out by using theopportunities of the clinical observer.

THE DANGERS OF

UNABSORBABLE SUTURES IN GASTRO-ENTEROSTOMY.

WITH REPORT OF A CASE.

BY G. A. UPCOTT-GILL, F.R.C.S. EDIN.,MEDICAL SUPERINTENDENT, QUEEN’S HOSPITAL, SIDCUP ;

AND

H. B. JONES, M.R.C.S. ENG.,RESIDENT SURGICAL OFFICER TO THE HOSPITAL.

THE following case illustrates the unfortunate

results of the usage of thread or silk as a suture inentero-anastomosis.

The patient, a soldier, aged 37, was admitted to Queen’sHospital, Sidcup, Kent, on Sept. 3rd, 1923, with a historyof abdominal pain and vomiting for six years, and of aperforated duodenal ulcer and laparotomy on March 29th,1922, and a subsequent laparotomy with posterior gastro-enterostomy on Oct. 10th, 1922. He stated that since thelast operation he had had constant recurrence of pain andvomiting, the attacks lasting three days to two weeks, withperiodical intermission.

S‘ymptons.-(1) Pain, gnawing in nature, in the lefthalf of the epigastrium, lasting two to three hours, buteased by taking food or by lying down. Patient wokeabout 10 P.M. to 3 A.M. every night through discomfort.He was relieved by hot fluids, bismuth, or hot flannels.(2) Vomiting was rapidly induced by the pain, which itrelieved ; dark in colour, bitter, slimy in nature. Heavyfoods-e.g., meat, potatoes, &c.-accentuated the pain andvomiting. (3) Haematemesis. There had been three attacksof haematemesis since the last operation. Bowels not consti-pated ; appetite very good ; had lost weight.Abdominal Examination.-Two well-healed laparotomy

scars ; no hernia. Splashing and gurgling over a muchdilated stomach ; tenderness in the left half of the epigastricO 3

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region with slight general abdominal rigidity. Nothingelse abnormal detected.X Ray and Bismuth Meal (screen and film).-Duodenal

cap normal and no tenderness in this region. Large intestineslightly ptosed. First fractional test-meal (Oct. 15th, 1923) :Increased total acidity and free HC1—viz., 60 to 146 percent. From Oct. 16th to Dec. 15th, 1923, patient waskept under observation with light fish diet, large doses

of alkalis and belladonna, but showed no improvementin his symptoms or general condition. Second fractionaltest-meal: Showed marked hyperacidity in excess ofOct. 15th. Thus the total acidity varied from 55 to80 per cent. ; in two and a quarter hours it reached100 per cent. Free HC1 55 per cent. (0-205 to 0-235).

General Health.-The man looked ill and wearied ; muddycomplexion. Tongue furred, teeth fair, pharynx congested.Is of alcoholic habit. Nothing abnormal in chest, renal, ornervous systems.Diagnosis.-The recent history of characteristic pain and

vomiting, the hsematemesis, the marked hyperaciditydespite a previous gastro-enterostomy, pointed to freshulceration, probably gastro-jejunal.

Operation (Jan. 4th, 1924).-Anaesthesia, gas and oxygeninduction followed by spinal anaesthesia (stovaine). Supra-umbilical incision. On opening the peritoneal cavity manyadhesions were found. All of these were separated andligatured or transfixed. The stoma of the old posteriorgastro-enterostomy was examined and found barely toadmit two fingers, and to have a hard, unyielding edge.Palpation of the stomach did not disclose any otherabnormality. The stomach was’ then opened above thecardiac side of the anastomotic opening. There immediatelypresented a dark, hard mass the size of a cherry (afterwardsfound to be blood-clot), connected to the stoma by a long,loose pedicle. This was recognised as an old thread suture.The gastric opening was then closed and another openingmade which gave better access to the anastomosis. It wasnow obvious that the thread suture had been used for theprevious gastro-enterostomy, and had partially ulceratedout, so that the two strands were still connected to theanterior and posterior lips of the stoma, while the unattachedends, matted up with old blood-clot, moved freely in thegastric cavity. There was a large crater-like ulcer involvingthe anterior and posterior walls of the stoma for about two-thirds of the circumference. This extended upwards anddownwards into the stomach and jejunum respectively.The whole anastomosis, with an inch of stomach and jejunum,excised. New posterior anastomosis made, using 30-daycatgut and Souttar’s needles. Scar of old duodenal ulceralmost healed, but slight pyloric stenosis persisted. Nothingelse found. Abdomen closed in the usual manner.

Progress after Operation.-The patient made an uninter-rupted recovery, and was allowed to get up in 28 days time. IHe was given large doses of alkalis and paraffin withan occasional aperient, and kept strictly on fish diet. Heoccasionally had a sharp pain in the upper right abdominalquadrant on turning over, but this has gradually decreasedand should disappear.

Conclusions.This case very aptly illustrates two important ipoints (to which Woosley 1 dretw attention in a similar

case). (1) That the use of unabsorbable suture is amistake in gastro-intestinal surgery ; the suture ofchoice is chromic or tanned catgut. (2) If a gastro-jejunal ulcer develops it should be treated surgically andnot medically-i.e., by excision of the original anasto-mosis and the ulcer, and a reconstruction nearer thelesser curvature. Both Walton 2 and Gronnerud 3have given up silk or thread suture, and lay stress ontheir experience that since abandonment in favourof catgut they have had no incidence of peptic ulcer.Wright 4 describes a case where silk was used for ananterior gastro-enterostomy which was followed in thesame year by a gastro-jejunal ulcer. This was infolded,but eventually perforated. Complete excision and a I

posterior gastro-enterostomy had then to be carried out, with no recurrence of any trouble two yearslater. He makes the striking statement that hisrecords show 13 cases of gastro-jejunal ulceration dueto silk suture. Adams records the occurrence ofa gastro-jejunal ulcer three years after anastomosis ;a silk knot was found in the centre of the ulcer.With such striking evidence before him of the

disasters liable to follow the use of unabsorbablesuture the surgeon should surely turn to othermaterial. Thirty-day catgut, preferably on a Souttar’sneedle, supplies the want.

(Continued at foot of next eolurnn.)

1. J. H. Woosley: Surg. Clinics, N. Amer., iii., 656-671. 2. A. J.Walton : Surgical Dyspepsias, pp. 350-360. 3. P. Gronnerud :Etiological Relations of the Sequelæ of Gastro-Enterestomy, Ann.Surg., 1917, lxvii., 177-183. 4. G. Wright: Brit. Jour. of Surg.,1919, vi., 390-393. 5. J. W. Adams : THE LANCET, 1922, i., 16.

LESIONS OF THE TRACHEA IN

PULMONARY TUBERCULOSIS.BY FREDERICK R. G. HEAF, M.D. CAMB.,

MEDICAL SUPERINTENDENT, WARWICKSHIRE KING EDWARD VII.MEMORIAL SANATORIUM.

THE anatomical situation and inaccessibility of thetrachea may account for the small amount of considera-tion which it has received in cases of pulmonarytuberculosis. Yet by virtue of its position it certainlydeserves attention, as it is a channel of considerablelength through which many virulent organisms passon their way to or from the lungs.My interest in the trachea was first aroused by

noticing its condition in a series of 133 autopsies oncases of pulmonary tuberculosis at Colindale Hospital,Hendon. In this series r found the trachea showedabnormal features in 44 per cent. of the cases. A smallamount of congestion of the mucous membrane was nottaken into account in arriving at this figure, as it waspresent in almost all the cases.The lesion varied from a slight oedema of the mucous

membrane to a general ulceration of the whole surface,’and it was therefore possible to form a good ideaof the sequence of events. The mucous membranebecomes increasingly congested until it is a deeppurple in colour and considerably thickened by oedema.The surface then begins to desquamate and smallsuperficial ulcers form. These gradually coalesce sothat a large irregular shallow ulcer is formed, having aslightly raised edge but with very little induration.The walls are ragged and soft, and are surrounded byan area of deeply congested tissue. The lesion isgenerally confined to the area just proximal to thebifurcation of the trachea, but occasionally assumes adiffuse form, the whole surface of the trachea becomingcovered with numerous irregular shallow ulcers.

In 68 per cent. of the cases in which ulceration waspresent the lesion was more pronounced on the rightside, but occasionally it becomes localised in themiddle line and then the ulceration assumes a morepenetrating character, and the lesion is deep withindurated walls. In one of my cases the base of theulcer exposed the pre-tracheal muscles and fascia overan area half an inch in diameter, almost constitutinga spontaneous tracheotomy. The relation of ulcerationof the trachea to that of the larynx was worked outin order to determine the relation between them, butit was found that in the 58 cases which showed apathological condition of the trachea the coexistenceof definite ulceration of the trachea with infiltrationor ulceration of the larynx occurred in all but two cases,although in the 81 cases of laryngeal tuberculosis (bothextensive and slight) the trachea escaped 25 times.This compares fairly favourably with the BromptonHospital figures, in which series of 214 cases the tracheawas affected and the larynx escaped 13 times, but 74cases showed ulceration of both larynx and trachea.On reviewing the clinical notes of the cases which

exhibited gross tracheal lesions, I found that all thepatients had complained of a loud distressing cough ofa paroxysmal character and very refractory to treat-ment. With the cough there was deep-seated retro-sternal pain and a raw aching sensation across thechest after a bout of coughing. All the cases sufferedfrom dyspnoea and a feeling of tightness across thechest. None exhibited any superficial tenderness overthe sternum. Generally there was little sputum, andthe lungs at autopsy displayed extensive fibrosis.

Treatment seems to have been difficult and at mostonly palliative, but a fair amount of relief from thepainful bouts of coughing was obtained by frequentinsufflations of pulv. aneesthesin and orthoform inequal parts, administered through a Leduc’s tube.

(Continued from previous column.)UNABSORBABLE SUTURES : REFERENCES.