ABDOMEN OMENTAL FIXATION.
The Operative Treatment of Ascites due to Hepatic Cirrhosis by Means of Omental Fixation. The author instituted a series of experi ments on dogs to find how much influence was exercised on the portal circulation by new-formed adhesions from omental fixation, and how such procedures caused anastomoses between the portal vein and the inferior vena cava.
In his experiments Kusnetzow proceeded as follows: (I) Complete ligation of the peripheral branches of the portal system, (a) the large, (b) the small mesenteric veins, or, (c) several smaller branches of the above at the same time: the venae duo denojejunalis and gastroduodenalis, or the gastroduodenalis and mesenterica. minor ; (2) ligation of the portal trunk, either complete or partial, i.e., its calibre reduced one-half or one-third.
Each dog was operated on two or three times. At the first operation omental fixation was practised ; at the second a mes enteric vein was ligated or the peripheral portion of the portal vein; at the third operation the central portion of the portal vein was ligated, i.e., near the liver. Only one dog out of fifteen died, the rest were killed from one to three months after operation. The author comes to the following conclusions : ( ) Good results follow omental fixation in cases of ascites due to impeded portal circulation.
(2) Talma's operation is preferable to Delagenieres.
(3) Complete ligation of the portal vein without preliminary omental fixation is rapidly fatal.
(4) Omental fixation enables animals to withstand double ligation of the portal vein.
(5) Complete ligation of the portal vein below the " gastro lienalis" causes early death even after a preliminary °mental fixation, (6) After omental fixation, incomplete ligation of the portal vein in its middle section leads to engorgement and temporary diarrhoea, but the animal soon recovers.
(7) The superficial epigastric veins dilate markedly after omental fixation, and more particularly after portal ligation.
(8) The veins of the large omentum dilate and soon com municate with those of the abdominal wall. The route taken is from the portal vein through the " gastrolienalis" (gastro-epi ploic) to the omental veins, thence via the epigastrics to the femoral, intercostal, or mammary veins.
(9) Direct communication exists and becomes increased be tween the portal vein and the vena cava by means of a number of small veins. This supports Sappey's views. Wratsch, 1900, Nos. 32 and 33; Centralblatt fiir Chirurgie, 1901, No. 4.
II. Surgical Pathology of the Omentum and Mesentery. By PROF. PAUL L. FRIEDRICH (Leipzig). Friedrich observed last year, in three cases, a transitory icterus follow herniotomy in middle-aged men. In each case much omentum was resected. Von Eiselsberg has noticed ulceration of the stomach following omental resection and even extensive ligations in the mesorectum, which he attributes to extensive thrombosis which reaches the gastric arteries.
Friedrich undertook an experimental investigation, hoping to explain the above phenomena. In guinea-pig excision of the omentum, or ligation of omental vessels, even when the area operated on was very small (e.g., one-third to two-thirds of the omentum), was followed by multiple simple anxmic and hmmor rhagic necroses of the liver. In a not inconsiderable number of cases where the ligations were close to the epiploic artery, one or more ulcers appeared in the stomach. According to the time which elapsed between the operation and the obduction the gas tric lesions consisted in hmmorrhages in the mucosa, epithelial necrosis, and distinct ulcers. The ulcers usually were located in the territory supplied by the inferior epiploic artery. Archiv fiir klinische Chirurgie, Band lxi, 998.
A LOOP AROUND THE HYOID BONE AS AN AID IN NARCOSIS DURING CERTAIN OPERA TIONS ON THE LOWER JAW AND IN THE MOUTH, AND IN AFTERTREATMENT.
About ten years ago I lost a patient after extirpation of one-half of the inferior maxilla, including the whole of the middle portion of the bone, together with the muscles of the floor of the mouth, the operation being rendered necessary by carcinoma. The patient died suddenly during the following night. When seen in the evening, his condition was good ; when seen at midnight by the nurse, he was awake and well and went to sleep; about an hour later, the nurse found him dead. No other explanation for this death could be found than asphyxia from the sinking back of the tongue during sleep, the tongue and larynx being deprived of the muscles which connected them with the lower jaw.
As a result of this experience, after resection of one-half of the lower maxilla, I have always allowed a loop of silver wire or silk, passed through the anterior portion of the divided bone, to remain, the ends being brought out through the dress ing, so that the nurse or patient might pull on it if dyspncea should arise. This precaution is sufficient only when the muscles extending from the hyoid bone to the maxilla are intact on one side, and if it can be seen during the operation that the entrance to the larynx is made free by traction on the end of the bone left.
In case of removal of the floor of the mouth for malig nant tumors, when all the muscles from the body of the inferior maxilla backward to the tongue and hyoid bone are removed, the tongue and larynx with the epiglottis have necessarily lost their attachment to the maxilla, and will sink backward against the posterior wall of the pharynx, causing occlusion of the entrance to the larynx and strangulation, espe cially during sleep.
During narcosis, this difficulty is obviated to a great ex tent if the tongue, can be pulled out of the mouth in a longi tudinal direction. This cannot be accomplished when the jaws are closed and fixed, so that the mouth cannot be opened nor access gained to the tongue, as in operations for osseous ankylosis of the jaw.
Further, I have observed that in the Regnoli-Billroth operation; that is, the operation for the removal of the floor of the mouth or tongue through a horseshoe-shaped incision below the maxilla, when the tongue is pulled out of the infra maxillary opening, not in a longitudinal direction, at right angles to the posterior wall of the pharynx, but in a downward direction, where it forms an acute angle with the frontal plane ; under such conditions, when, during narcosis, there is difficulty in maintaining a free entrance to the larynx, this difficulty is best obviated by making traction on the hyoid bone by means of a sharp hook as advised by Kappeler, or by a loop passed around the body of the bone which I have found to be more convenient, and which, after having used for several years in at least a dozen cases and found without danger, I recommend.
The value of this procedure has been demonstrated over and over again during long operations, so that the students in the amphitheatre could easily observe the change from labored and noisy respiration to free and noiseless respiration as soon as traction was niade on the loop.
It is impossible for the assistant who gives the anzsthetic to hold a sharp hook around the hyoid bone for a long time, possibly for hours, while he can manage a loop of silk passed around the hyoid bone just as easily as a loop passed through the tongue. The loop is not needed for an emergency; that is, for an attack of asphyxia during narcosis, where the sharp hook will be sufficient; but it is needed during the entire nar cosis, because, as I have seen in these classes of cases, asphyxia supervenes the moment traction on the hyoid bone is released, and is followed by perfectly free respiration when traction is again made.
There is another reason why it is important that the space behind the larynx should not be half obstructed, but be perfectly free with space to spare if possible; namely, because it is impossible to keep the pharynx free from the frothy mucus. If one-half of the entrance to the larynx be obstructed, the inferior half lying against the wall of the pharynx, there is no space for the mucus, and therefore it must be aspirated down into the larynx, and the air must pass through it and tend to bring it down. On the other hand, if the larynx is perfectly free, and if there is more room behind it than is actually necessary, there will be less aspiration of mucus, and possibly less bronchitis or broncho-pneumonia, following the operation.
In discussing the measures against respiratory troubles caused by the tongue and the epiglottis during anmsthesia, or, rather, while the anasthetic is being administered, Kappeler 1 stated in 188o that the following methods are employed : (I) Howard. Elevation of the thorax to let the head and neck sink backward.
(2) Lifting of the lower jaw, devised by an Englishman (Little ( ?) ), introduced in Germany by Von Esmarch, and first minutely described by Heiberg.
(3) Pulling out the tongue with tongue-forceps and lift ing the epiglottis with the finger (Howard).
Although the manipulation of Howard, namely, elevation of the thorax, and the lifting of the jaw described by Heiberg, are, as a rule, sufficient during deep narcosis, they are not sufficiently effective during the initial stage of excitation, when there is a spastic retraction of the tongue, and spasm of the muscles of the jaw which often necessitate forcible open ing of the mouth with a gag, pulling out of the tongue, and direct lifting of the epiglottis. In alcoholics, who present a protracted stage of excitation and vigorous, obstinate retrac tion of the tongue, he prefers to pass a loop of silk through the tongue and pull it out with no more injury to the organ than occurs from the use of the tongue-forceps.
In a foot-note on page 127 he mentions the hyoid bone briefly as follows : "Recently I have succeeded in avoiding the rough manip ulation necessary to separate the jaws during the tetanic clo sure of the mouth, by resorting to an easy and only slightly injurious method ; namely, lifting of the hyoid bone forward. I passed a small, strong, pointed hook up behind the middle of the body of the hyoid bone and hooked it into the bone, which was then pulled forward. The tongue and epiglottis followed the hyoid bone in its forward movement, the epiglottis from traction on the hyo-epiglottic ligament.
"I observed without exception that the respiration became free when this manipulation was resorted to during asphyxia in chloroform narcosis, caused by closure of the entrance to the larynx." To demonstrate the effectiveness of the different manip ulations to allow free passage of air into the larynx, Kappeler made experiments on the cadaver, which I have verified and completed as shown by the accompanying figures.
When the calvarium has been removed, as is usually done in post-mortem examinations, and the brain taken out, the whole basilar portion of the occipital bone and the body of the sphenoid as far as the posterior clinoid processes are removed with a chisel and the pharynx opened from above. A clear view can now be obtained of the upper (posterior) surface of the soft palate and the root of the tongue below it. If, in cli.se of small skulls, the view into the pharynx is not sufficiently free, The head is then placed in a horizontal position or on a small pillow, whereupon the soft palate can be seen lying against the posterior wall of the pharynx, either entirely so or separated from it by a narrow slit through which the upper ridge of the epiglottis may be seen. (Fig. 1.) If the chin is now lifted up, the mouth being closed, the soft palate moves forward away from the wall of the pharynx, and we see the root of the tongue and the upper border of the epiglottis; but its whole posterior surface still lies close to the posterior wall of the pharynx. (Fig. 2.) If the tongue is now pulled forward out of the mouth in front of the teeth, it is seen that the posterior part of the tongue moves forward away from the epiglottis, and the median glosso-epiglottic ligaments come into view, while the epiglottis is either not moved at all or makes only a slight for ward movement. (Fig. 3.) If the lower jaw is now lifted forward by pushing the descending rami upward when the patient is recumbent, or forward when the patient is upright (Howard ( ?)), the epi glottis moves forward, so as to free the entire upper (an terior) half of the entrance to the larynx. (Fig. 4.) It will thus be seen that this manipulation alone is much more effective than pulling out the tongue. If the tongue is now pulled forward while the jaw is lifted forward, the epi glottis is moved a little forward, but only very little, and not beyond the border of the soft palate.
If the hyoid bone is now pulled forward, either by the sharp hook of Kappeler or by the loop as devised by me, the mouth closed and the tongue untouched, the posterior (lower) half of the entrance to the larynx is made free, and the anterior (upper) half of the larynx is covered by the root of the tongue, which also covers the epiglottis. (Fig. 5.) If, in addition to the pulling forward of the hyoid bone, traction is made on the tongue, the whole of the entrance to the larynx is made free. The tongue and epiglottis have dis appeared forward under the soft palate. It is really the pull ing forward of the hyoid bone that frees the entrance to the larynx from the wall of the pharynx, with room to spare. (Fig. 6.) It will be seen from the plates that traction on the hyoid bone is far more effective than any other method, because this is the only manipulation that makes the entire posterior com missure of the larynx with the arytenoid cartilages visible. This it accomplishes by lifting them from the posterior wall of the pharynx. It is, therefore, only by pulling the hyoid bone forward that the entire entrance to the larynx is made free.
Through a small longitudinal incision over the middle of the body of the hyoid bone, it is easy, by means of an aneu rism-needle, to pass a loop of silk around the posterior surface of the body, up over the upper border, and out through the wound. A small pad of iodoform gauze is packed in the wound and the loop tied over it, the ends being left long enough to permit of manipulation by the operator or anxs thetizer during the operation. At the close of the operation, the loop is left in place and attached to a plaster-of-Paris cast loosely covering the dressing at the field of operation, with traction on the hyoid bone sufficient to prevent any sinking back of the larynx and epiglottis, and thus to keep the en trance to the larynx open even during sleep. I usually allow the loop to remain for three or four days, until the patient is able to breathe without difficulty with the head and body in any position. It is needless to add that the small wound over the hyoid bone adds nothing to the gravity of the operation.