Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 138

Author: Jacob Anthony Kimmell
Publication date: 1910
Publisher:
Number of Pages: 1189

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Perhaps less striking, but to my mind even more remark- able, is the completeness with which the peritoneum may absorb adhesions, and indeed completely eradicate all traces that would indicate their previous existence. From the evi- dence in hand it would seem to be a perfectly safe assertion to make that adhesions invariably follow laparotomy, yet how common it is nowadays to find no traces of them at a later second laparotomy !

Now obviously, all of these fundamental and important characteristics of the peritoneum, which are familiar to every- one, must be reckoned with in studying the process of adhesion formation, and in any attempt to control or prevent it. Happily we now know, as a result of much careful experi- mental and clinical study, quite accurately the pathological changes involved. Categorically stated, they are, in order of sequence, injury or death of the endothelium, pouring out of coagulable exudate, agglutination, organization, fibrous tissue formation, and a final termination in a contracted scar. There is a very attractive theory, supported by creditable experimental work, that the permanence or subsequent reso- lution of adhesions depends upon the fate of the surface endothelium. If the cells are capable of recovering from in- sult sustained, the process of adhesion formation advances no farther than the stage of agglutination, and later entirely disappears; but if, on the other hand, the injury has been sufficient to effect the death of the endothelium, organization proceeds and the adhesions become permanent. It seems to me, however, that further experimental confirmation is needed before we can accept this view without modification.

In view of the pathology of peritoneal adhesions just lined, it is not surprising to find the bulk of the literater their etiology concerned with a study of the various sens ordinarily coming in contact with the peritoneum the: .: be considered inimical to the vitality of its endotheliun : the sake of brevity and clearness we may classify these . tributions according to subject-matter as follows: (1) N. (2) Sutures and Ligatures; (3) Eschar of the Tie cautery ; (4) Air; (5) Infection; (6) Mechanical, Chez. and other Agents.

Blood .- The final verdict has not yet been given Na". the relationship of free blood in the peritoneal carity :. hesion formation. After carefully and impartially wir the evidence before me, however, and in the light of my observations, especially in cases of ectopic pregnancy, my deliberate judgment that blood alone does not c. peritoneal adhesions. Although frequently associated. : presence of adhesions can always, in my opinion, ber rationally explained in other ways than on the assumpta irritation from the blood.

Sutures and Ligatures .- Much of the older literatt: to do with the question as to whether or not aseptic & ... and ligatures constitute an important factor in the pri tion of adhesions. Mass ligatures and pedicle stumps. are accorded significant consideration. But while this . subject of the ultimate fate of the various sutures and .: tures used in the tissues of the peritoneal cavity furnis'- study of absorbing interest, I shall have here to assume ft. iarity with it, and dismiss the matter with the statemer: where one exercises good surgical judgment and mat dexterity in the choice and application of aseptic suture. ligatures, no grave fears need be entertained as to troubles: adhesions arising from this source.

Eschar of the Thermo-cautery .- The results of the era mental work on the use of the thermo-cautery in the peritos cavity have been somewhat conflicting. The reason for : probably to be found in a fact brought out by some ch : later work, namely, that a superficial burning generally g. rise to adhesions, while a deep thorough cauterization the formation of a thick eschar, does not produce adhes. The explanation offered is that the charred surface preir the granulating surface beneath from exposure until it : comes covered with new endothelium. However trois may be, the weight of experimental and clinical erit's certainly warrants the thorough application of the car when indicated with far less likelihood of adhesions en. than if certain other procedures applicable to the same . ditions are substituted.

Air .- Exposure of the viscera to the air is recognize- course, as one of the cardinal factors in the productic: surgical shock. It may not be so generally known, h that much experimental work of the highest order has done to ascertain the effect of the air on the peritones. dothelium, and its relation to adhesion formation. [ .. tunately, here again the results are conflicting; br" : evidence is decidedly in support of the view that the air.

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18 that rapid absorption of heat and moisture from peritoneal surfaces occurs, and as a result of this drying cooling process, a necrosis of the endothelial cells is pro- ed, with resulting contraction of the blood vessels and inished nutrition, all of which stand in etiological rela- ship to adhesion formation. Thus, aside from the pre- ion of shock, we have an additional very important reason carefully protecting all parts of the peritoneum from un- exposure during the course of abdominal operations. ifection .- No one doubts, of course, that infection pro- 's adhesions. But there seems to be much difference of ion as to the formation of adhesions without infection. umber of observers have called attention to the gradual ng off in the number of adhesion cases seen in the clinics esponding with the improvement in surgical technique. e have interpreted the remaining incidence, however, as lusive evidence that our methods are still imperfect as rds asepsis.

he work of the experimental investigators, while admirable ts thoroughness, has unfortunately confused rather than lified matters, by reason of the conflicting results ob- ed. No phase of this whole subject has evoked a sharper roversy than the question of infection in its relation to sion formation, and the alignment can be sharply drawn 'een the adherents of two views: (1) those who hold that tion is the sole cause of adhesions; (2) those who hold ction to be the chief cause, but admit that they do result 1 various other causes acting independently or collectively. latter group are unquestionably right, as is conclusively en, not only from a comprehensive study of the whole lem of adhesion formation, but indeed is tacitly admitted heir opponents through the conspicuous absence of any it substantiation of their claims. No one, as far as I ", is contending nowadays that adhesions can only be uced by infection.

chanical, Chemical and other Agents .- Under this head- tre to be included nearly all of the various fluids and icals formerly so extensively used and constituting the r part of antiseptic surgical technique. All this has replaced, of course, by our modern aseptic methods, and xperimental as well as the clinical evidence testifies un- bly to a consequent diminution in the number of ad- 1 cases seen.

undant experimental proof is available to support the ally accepted view that raw surfaces, resulting from ; mechanical insult to the peritoneum, are one of the onest, if not the most frequent, cause of adhesions. So, ›reign bodies inadvertently left in the abdominal cavity, Ul as the various types of drains purposely introduced, ably provoke adhesions. In this connection too much usis cannot be given to the importance of exercising the t care and gentleness in all intraperitoneal manipula-

Rough handling of the viscera; unintelligent, and I say sometimes almost brutal, use of retractors and

materially to the comfort of the operator, but more to the distress of the patient; the application of dry gauzes to the peritoneal surfaces, which generally adhere, and when removed often bring away with them the surface endothelium; un- necessary sponging, as a sort of surgical tic or habit spasm; careless application of hæmostats, with painful indifference to the mass of crushed tissue left to necrose in the grip of the ligature-all of these constitute transgressions of which few of us can claim innocence. But they also constitute a pro- lific source of adhesions, and should therefore be constantly borne in mind in order to impress upon us the value and im- portance of diligently cultivating a healthy aversion to un- necessary trauma, and a profound respect for the tissues.

Coming now to a consideration of the prevention and treat- ment of adhesions certain prophylactic measures at once suggest themselves as being clearly indicated from what has already been said. Briefly stated these are-rigid asepsis; avoidance of mechanical, chemical or thermic trauma; care- ful covering up of all raw surfaces; use of hot moist gauze; and avoiding exposure of the peritoneum to the air. Thus far, practically everyone is agreed. But the common experience that troublesome and dangerous adhesions still quite fre- quently occur, in spite of the strictest possible observance of these measures, has stimulated investigators to undertake the most varied and elaborate researches with the hope of dis- covering some prophylactic or remedial agent that would prove efficacious in all cases. This work has resulted in the production of many ingenious and valuable procedures, all of which have at one time or another been enthusiastically advo- cated, and have received varying degrees of support from the profession generally. Most of them have been sufficiently tested now to admit of a pretty accurate opinion being formu- lated empirically, as to their actual worth. From a study of the numerous reports the following classification and valua- tion of these heterogeneous devices seems warranted.

1. Non-Absorbable Protective Membranes .- Under this caption may be included the covering of raw surfaces with collodion film; gelatin-formalin coagulum; lymph-aristol coagulum ; silver foil; solution of gutta-percha in chloroform, carbon bisulphid, or xylol; and thin sheets of silk or rubber fabric.

None of these agencies can be relied upon to furnish more than a small percentage of uniform and successful results, and on this account, cannot be recommended for general use.

2. Manual and Postural Arrangement of the Viscera .- This is accomplished partly through proper disposal of the viscera with reference to normal anatomical relationship at the end of the operation, and partly through post-operative posture in the ward, with the double idea of avoiding permanent kinks at those movable parts of the gastro-intestinal canal which commonly produce untoward symptoms-such as the pylorus, upper part of jejunum, lower ileum, cæcum, transverse colon, and sigmoid-and for the further purpose of gravitating the abdominal contents away from raw surfaces. Both of these

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procedures seem rational and worthy of more general con- sideration and use.

3. Peristalsis .- Considerable work has been done on the post-operative use of physostigmin, with the idea of stimu- lating strong peristalsis, and thus liberating early adhesions and preventing their recurrence. Conflicting results have been reported, however, and the routine use of this drug is of doubtful value.

4. Specific Drugs .- Iodides have been recommended with the idea that they inhibit proliferation of connective tissue, and aid in its absorption. Thiosinamin, and its combination wth salicylate of sodium, known as fibrolysin, have been ac- credited with possessing a softening influence upon cicatrices and other abnormal growths of connective tissue.

The use of various anti-fibrin ferments, with the intention of preventing coagulation of exuded serum-the first essential stage in adhesion formation-have been also tested experi- mentally and recommended. An encouraging increase of suc- cess has attended this pioneer work in an effort to apply specific chemo-therapy to the problem of peritoneal adhesions, and further development along this line is to be confidently expected.

5. Normal salt solution in large quantity poured into the abdomen at the end of the operation in order to float the loops of bowel into their normal relationship and keep denuded surfaces separated, was at one time extensively used. Later on adrenalin was added, with the idea of preventing exudate through its constricting action on the vessels. But it has been shown that absorption is too rapid to admit of much new growth of endothelium over raw surfaces before they again come into contact with adjacent tissues.

6. Gases .- Distention of the abdomen with oxygen gas just prior to closure of the peritoneum has been recently suggested as a useful resuscitating and anti-adhesion measure. So, too, intra-abdominal hyperæmia, brought about by periodic local application of the hot-air bath to the lower trunk has been recently quite warmly advocated.

7. Eschar of the Thermo-cautery .- As already indicated, if this measure is utilized, the cauterization should be very thorough, so as to form a deep and lasting charring of the tissues. This measure undoubtedly possesses distinct ad- vantages under certain conditions.

8. Lubricants .- Because of their harmlessness, ease of ap- plication, and apparent effectiveness in many cases, various oily and fatty substances are perhaps more extensively used than any other single artificial measure in the treatment of adhesions. A number of substances of this kind have been suggested from time to time and carefully studied experi- mentally; including olive oil, vaseline oil, liquid lanolin, liquid petrolatum, and others. Vaseline oil seems to possess certain advantages, notably the fact that irritating fatty acids are not so readily split off from it during the process of sterilization, as is the case with olive oil. The sterilization should be carefully done, and the temperature not carried too high for this reason.

9. Non-Viable Animal Membranes .- Cargyle membrane,

made from the peritoneum of the ox; a similar memira from the shark's peritoneum ; goldbeaters' skin, derived foz the outer coat of the caecum of the ox; and a fine woven tr. made of catgut, constitute the members of this pro- Cargyle membrane has been more extensively used that c: of these, but in the hands of some investigators it has pre miserable results, and even its most enthusiastic adriane admit its failure in a number of instances. Theoreticalx : is surprising that these membranes do not uniformly pres rather than prevent adhesions-and there is considerat're perimental evidence in support of this view-inasmuch : piece of dead animal tissue that has been kept in present .: fluids, although it may later undergo absorption, is in er sense of the word, a true foreign body while it remains in : peritoneal cavity, and must be so regarded in its relaticz:" adhesion formation. It seems to me inevitable, there's that these substances will gradually fall into disuse.

10. Viable Grafts .- Much more rational are the effort : cover raw surfaces by plastic operations on the peritoxz or by autogenous grafts of omentum. It has been d'or. experimentally that if the entire omentum of dogs be ex: tated and simply dropped into the peritoneal cavity, it d- not undergo necrosis, but on the contrary, quickly beercs spread out over the parietal peritoneum, to which it adh :. and promptly becomes vascularized.

Furthermore, it has been shown that omental grafts ap- to denuded bowel surface establish sufficient vascular cez munication to admit of injection from the aorta with an' fluids within the surprisingly short period of twenty-fr. hours. Again, no one has reported, as far as I know, 23 . stance of necrosis of an omental graft. But unfortuna: they do not prevent adhesions, except when applied to abdominal parietes and to organs possessing strong perist's such as the stomach and urinary bladder. On the small kr: they are very useful in reinforcing weak points and st." lines, but here they invariably adhere to neighboring loops

It is evident, therefore, that grafts of fresh omentum peritoneum have a very important and wide field of app ?? tion, and it seems quite feasible to have at hand in the opens ing room, just prior to operations upon bad adhesion ci- an abundant supply of peritoneum obtained from & fns slaughtered calf, under aseptic conditions, and caref .: guarded from mechanical or chemical trauma, for extens" application.

A NEW METHOD OF TREATING RAW BOWEL SURFACES

A few months ago during the course of an operation = the relief of an enormous post-operative ventral hernis a situation arose which suggested to me a new, and what ! believe to be an eminently satisfactory method of dealing denuded bowel surface under certain conditions. The pati: was a very large, fat woman, well past middle life, who, reason of circulatory and renal disease, was rather 3 px; surgical risk. Moreover, about six months previously she ba! undergone a very serious operation for radical removal of generative organs on account of a moderately advanced cac:

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ting hernia. Occupying the hernial sac, besides a bulky entum densely adherent throughout, there was a long loop ileum, coiled in a horse-shoe fashion, each limb of which I become so intimately adherent to the peritoneal lining the sac as to render separation along any definite line of avage impossible. The two limbs were also adherent to h other by several transverse bands of dense fibrous tissue. :er effecting the release of the intestine I had, therefore, › extensive raw areas, each measuring two to three inches length, involving nearly one-half the circumference of the rel, and separated from each other by six or eight inches of ctically normal intestine.

Another factor of great surgical importance was the ex- sive dissection necessary to cure the hernia, by reason of wide separation of the recti muscles, the enormous size of opening, the abundant scar tissue produced by the old

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G. 1 .- An extensive denuded area on the surface of the ileum ere shown. Observe that at its widest portion a-b it involves ly one-half of the circumference of the bowel. The liberal sit of fat in the mesentery here represented admits of the y separation of its two peritoneal leaves. Note that the in- n for this purpose through the upper leaf is made about 1 cm. its bowel attachment, in order to avoid the numerous branch- vessels in this region. The separation of the flap d is now y and safely effected to any desired extent, since the average h of the mesentery is eight inches. A flat, blunt instrument- atula, for example-is best suited for this step. The rich ilar anastomosis between the mesenteric leaves, afforded by uperimposed colonnade arrangement of the trunk vessels, is 7 seen.

tion, and the atrophy and impaired vascularity of the es to be utilized in effecting the closure. These unfortu- circumstances, together with the patient's general con- 1, made it highly important that all possibility of wound tion should be serupulously avoided, as well as that every ole precaution should be taken against the occurrence of inal obstruction, which might necessitate the undoing of y work. Now, recalling the condition of the bowel sur- just described, it is evident, upon consideration, that of the customary methods of dealing with this complica- rere applicable to the conditions in hand. I could not, for

proximity to each other-obstruction would almost certainly have ensued. The various other measures already described were either impracticable or too unreliable, in view of the serious consequences of failure. I did not dare resort to lateral anastomosis, because I was dealing with the lower ileum ; and while this procedure would have taken care of the raw surfaces and obviated the danger of obstruction, it would at the same time have afforded an excellent opportunity for infection of the devitalized tissues of the wound, with com- plete destruction of all my plastic work, and immediate re- currence of the hernia. Fortunately, the problem was prac- tically solved for me by the accidental laceration and partial retraction of one leaflet of the mesenteric peritoneum just along its line of attachment to the bowel and adjacent to one of the raw areas on the surface of the latter, which occurred during its separation from the hernial sac (Fig. 1). There being a considerable deposit of fat between the two layers of

FIG. 2 .- The detached flap of peritoneum is here shown drawn up over the raw bowel surface and firmly fixed by interrupted sutures of fine silk. Note how completely and satisfactorily the defect has been remedied. Observe too, that, owing to the mo- bility of both the bowel and its mesentery, the mechanical effect on the bowel lumen and the mesenteric circulation is negligible, and cannot produce any serious consequences. Care must be taken to close the angles of the mesenteric flap just at the bowel margin, as shown, to avoid the possibility of an intra-mesenteric hernia.

mesenteric peritoneum, it was a surprisingly simple and easy procedure to extend the separation of the torn leaflet and its attached fat in all directions from the underlying vessels and the opposite intact leaflet with its fat, thus obtaining a large movable flap of normal peritoneum which was easily drawn up without tension, spread out over the raw surface on the bowel, and tacked down with a few fine silk sutures (Fig. 2). The result was eminently satisfactory in every way, this very simple device, which was quickly carried out, having sufficed to abolish a rather complex and embarrassing surgical situa- tion. The patient's recovery was complete and she is now comfortable and happy.

This fortunate experience led me to investigate the idea

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further in order to determine accurately its limitations and to meet certain theoretical objections.

Thus it was desirable to ascertain if the method could be applied to all portions of the intestinal tract; if the separation of the two peritoneal leaves of the mesentery could be rapidly effected, without injury to the vessels in poorly nourished in- dividuals whose mesentery usually contains very little fat; and if not, to consider the feasibility of lifting a fold of both leaves of the mesentery, without incising either, over the raw surfaces, thus effecting practically a plication of the mesen- tery-a modification of the method that would make it ap- plicable to these cases also (Fig. 4) ; to determine further what effect this axial rotation, or partial envelopment of the bowel within its own mesentery, would have on the caliber and direction of the lumen, with reference to obstruction; to in- vestigate to what extent it would be practicable to so treat

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FIG. 3 .- The bowel and its mesentery are here represented in cross-section. In the upper drawing, the area between a and b is the raw surface; c marks the point of incision through one peri- toneal leaf of the mesentery; and d the flap to be freed and drawn up. The lower drawing shows the flap d closely applied over the denuded area, and fixed by sutures which should pene- trate the submucosa.

the bowel, and to ascertain particularly what effect was pro- duced on the mesenteric and bowel circulation by this me- chanical alteration of normal conditions; and finally, how much tension the leaflet of mesenteric peritoneum is capable of withstanding, with reference to its being torn loose by post- operative distention or vigorous peristalsis.

The fresh cadaver seemed to offer the best method of set- tling these questions, and my conclusions, based upon such a study, are as follows :

1. The procedure is best applicable to that portion of the intestinal tract where, in such cases as the one described, present methods are inadequate, namely, from the upper jejunum to the lower ileum. It may be rationally applied,

however, to any portion of the bowel possessing & mesenter i sufficient length to admit of its ready execution.

2. Care must be exercised at the duodenum, upper jejuma. and lower ileum not to produce kinks of the bowel.

3. In cases exhibiting a scanty deposit of fat in the mex tery, plication is a rapid, safe and efficient substitute x separation of the two peritoneal leaves.

4. Aside from a slight spiral rotation, which in riend peristalsis and the mobility of the parts is entirely insufficient to produce obstruction, the procedure has no demonstri effect on the bowel lumen.

5. It can be safely extended to include nearly one ! the circumference of the bowel and three to four inches : continuity. There is no apparent reason why it should x be repeated as often as necessary at different levels of ty intestinal tract.

6. In view of the rich vascular anastomosis and the mobily of both the bowel and its mesentery, if care be exercised 3 placing the sutures so as to avoid the trunk vessels, the ede upon the circulation is negligible.

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Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 138

Author: Jacob Anthony Kimmell Publication date: 1910 Publisher: Number of Pages: 1189

Author: Jacob Anthony Kimmell
Publication date: 1910
Publisher:
Number of Pages: 1189