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J. A. (Joel Asaph) Allen.

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experimental line of investigation its solution will, in the main, rest.

Time and opportunity permitting, it will be my aim to continue
my experimental work, and test to the fullest this species of
automatic obturation in the human subject, and report final
results later..

EXPERIMENTS ON THE ABTEBIBS OF THE DOG TORSION TRANSFIXION

LIGATURE, AND HOMOLOGOUS LIGATION.

June 15, 1898, middle-sized terrier poodle. Animal anesthe-
tized with ether. Right femoral artery exposed in Scarpa's tri-
angle for about half an inch of its extent. Its sheath was divided,
the wall of the vessel lifted out, when it was caught, and the
entire caliber of the trunk compressed by two coarsely-toothed,
strong, clamp forceps. These were allowed to remain on ten
minutes, when they were removed. Immediately the lumen of
the vessel refilled, and the pulsations Were as vigorous as ever
beyond the point of compression.



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*2QS KANLBY : TORSION, ETC., OF DIVIDED ABTEBIES.

Now the two forceps were again applied over their previoas
site, when the vessel was divided with the scissors completely
through, after which the distal forceps was seized, and slight bat
steady traction made for a moment, when it was made to twist
the open end of the vessel until that extent of torsion was
reached that it could be carried no further without effecting jhe
complete detachment, of that part of the vessel engaged. Both
forceps, at this stage, were removed. The free orifice of the ves-
sel had been completely occluded. It freely pulsated with each
systole of the heart, but hemostasis had been complete. After
the divided parts had been duly prepared, they were approximated
and covered with dressings.

ACCIDENTAI. DIVISION OP THE LEFT FBMOBIX ABTEBY — PBOMPT AND

EFFECTIVE HEMOSTASIS BY THE TEMPOBABY TRANSFIXION

LI6ATUBB.

It was intended to repeat the same experiment on the left
femoral, at the same time, on the same animal. Not being aided
by ample assistants, and finding that the vessels on this side pur-
sued a rather abnormal course, the artery was accidentally
woui^ded and immediately gave issue to large jets of blood. As
it had been completely cut in two, both ends were quickly retracted
out of sight in the soft parts.

In this emergency, as ample facilities were not at hand to
search for and secure the spouting proximal end, the trunk was
compressed over the pubis, when a silk ligature, with a sharply
curved needle, was passed under the proximal segment of the
vessel, about half an inch posterior to the orifice. This ligature
included the loose connective tissue, the sheath, vctsa vcLsorem^
artery, and other structures. After being tied, one free end was
left out. Thus, the transfixion ligature effectually succeeded in
closing the lumen of the vessel and subduing all hemorrhage. The
incised parts were closed in by one row of continued suture, when
dressings were applied.

The dog came out of ether well, and was returned to his crib
June 30th.

The wounds over the inner side of the thighs were at this time
nearly healed. It was now intended to extend our investigations
into the carotid triangles by torsion on one vessel and homologous
ligation of the artery on the other side.



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MANLEY : TOBSION, ETC., OF DIVIDED ABTEBIES. 261>

The animal was placed under ether, and the sheath of the
yessel exposed on the right side, when it was noticed that he
ceased to breathe. In a moment he was dead.

Now, a very careful examination was made over the site of the
incisions, which exposed the femoral vessels, two weeks previously.
The right side was the first dealt with. Here it was found that
all the tissues had cicatrized into one homogeneous mass.

Tearing open this cicatrix, no trace of the artery could be
found until about two centimeters of the scar tissue was stripped
in the direction of the long axis of the limb in an upward direc-
tion, at which point the obturated cord-like proximal end of the
artery was discovered, though it was so intimately incorporated
with the cicatrix, in which it was imbedded, as to be only separated
with difficulty. By tracing this up a few lines, we came on the
artery, which was empty, except for a line above the point of
obliteration, at which point a decolorized, conical blood-clot was
found. The embolus was, even at this early stage, so blanched,
consolidated, and organized, as to clearly resemble connective
tissue.

The distal end was not so deeply decolorized as the proximal.
Its lumen was obliterated, not by an embolus, but by an adhesion
of its walls from an exudative endarteritis.

DISSECTION OF THE LEFT FEMORAL ARTERY.

On this side the temporary transfixion ligature had been
employed. Although the purpose of this ligature is to only serve
a momentary end in this case, it was allowed to remain on for
two days, after which time it was cut away, when no hemorrhage
followed.

In this dissection, as the former, it was seen that the injured
artery was caught and entangled in a mass of new tissue.

But it was continuous, though, from a point immediately below
Poupart's ligament, but the trunk of the femoral artery was obliter-
ated for about five centimeters, when the open lumen below was
reached.

As with the vessel on the right side, the proximal end was
firmly occluded by an organized, firmly adherent embolus.

It may be added that in both of these extremities, in which
simultaneously the femoral torrent was abruptly cut of, they
remained well nourished, and, on post-mortem examination, there
were no evidences of atrophic, wasting changes.



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270 MANLEY : TOB8ION, ETC., OF DIVIDBD ABTBBIKS.

BXPBBIMBNTS OK 8BCOND ANIMAL. '

July 6, 1893. (1) Homologous ligation of the proximal end
of the right carotid artery in the superior carotid triangle,
Olosare of the distal end by torsion. Completely saccessfal.
(2) Homologous ligation of the right femoral artery in Scarpa's
triangle. As the knot slipped, after the proximal end retracted,
the hemorrhage was now controlled by the temporary transfixion
ligature. The distal end of the artery was closed by torsion.

July l7th. Same animal, a bull-terrier, examined. All the
ligatures held. There was a moderate-sized exudation into the
eubcutaneous tissues at the point where the carotid was diyided ;
neither of the wounds healed ; primary union. Again anesthe-
tized and homologous ligation of the left femoral artery under-
taken. Here, on division of the tissues, such an anomalous state
of things was discovered as to render this species of arterial obtur-
ation rather impracticable. The vessel bifurcated in Scarpa's
triangle, and so ' wound around the femoral vein as to render its
isolation very difficult. Besides, the vein itself was lacerated, and
gave issue to a large effusion of blood before it could be controlled.
In this case, as the artery was wounded on manipulation, and it was
found necessary to apply a ligature directly over its proximal and
distal ends, our experiment on this occasion was an entire failure.

It was noticed, so far, in our experimental work, that the col-
lateral branches of the arteries in the dog are large and numerous,
«nd, hence, the suppressed circulation is very promptly reestab-
lished. This is apparent by the energy of the recurrent torrent
from the distal end of the vessel after division ; indeed, complete
t>btnration is as necessary here as with the cardiac end of the
vessel.

A singular peculiarity was noticed with the veins of the dog.
Their walls are proportionally very much thicker than with man,
and the energetic circulation through them demand well-directed
pressure to arrest it.

MISCELLANEOUS APPLICATION OF THE PBINCIPLB OF HOMOLOGOUS
OBTURATION IN CLOSING THE LUMINA OF CAVITIES AND SPACES.

Since this line of study and experimentation has occupied my
attention, it has occurred to me that if homologous obturation of
the arteries is feasible and practicable, then the field for the gen-
eral utilization of the living ligature, or suture, was, indeed, a
large one.



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manlbt: tobsion, etc., of diyidbd abtebibs. 271

On the 20th of July, this Summer (1893), a captain in the fire
department of this city came into my hospital service with a
strangulated hernia. ,On decortication of the sac, under cocani-
zation, with a redundant flap of fibro-serous tissue, in my hand,
the thought occurred to me, why not utilize this tissue to obturate
the inguinal canal ? Authors speak of stretching, twisting, furl-
ing, ligating, and excising the sac, in hernial operations ; but none,
that I am familiar with, have yet recommended utilizing it as a
knot for tying into a knot and closing in the ring.

In this instance, I split the sac in the direction of its long
axis, carrying the incision as far upward as the internal ring. I
then seized two loops and tied them in a triple-reef knot. After
the knot was fixed, it was pressed inward within the internal
ring. Then the other two loops were so tied as to overlap the first
knot. This was secured in a double-reef knot, when a catgut
suture was carried on a needle directly through it and the edges
of the pillars on either side, then firmly tied.

The incision was closed without drainage. Healing was
prompt ; constitutional symptoms, nil ; and our patient left the
hospital, soundly healed, in just two weeks.

Two weeks ago I resected a large plexus of veins on the inner
aspect of the leg and thigh of a young woman, when I found that
the homologous ligation of either ends of the vessels served an
admirable purpose as a ready and effective means of obturation.
The vessels were greatly dilated, and quite valueless, so that the
recurrent flow from the proximal divided end of the saphenous
required firm pressure to close it. But the living suture was
equal to the occasion.

Cases might be multiplied in which this expedient serves an
ideal purpose. When there is a sparcity of homologous tissue,
there is no reason why we should not reach out and utilize or bor-
row from a neighboring structure, as from the muscular sheaths,
aponeuroses, the nerve sheaths of nerves no longer needed, tendon,
integment, etc.

Without doubt, other investigators and operators will so per-
fect and extend the employment of this principle that, in the near
future, the technique will be so simplified and effective that no
sort of extraneous- ligature, or suture material, will be required for
any only very exceptional oases. Man, undoubtedly, carries within
himself all the necessary materials for the mechanical repair of
many traumatic lesions to which he is liable.



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272 ROBINSON : WHAT KILLS PATIENTS AFTBB LAPABATOMT ?

Time has proven that all chemical solutioDS are foreign sab-
stances, and that they have no place in healthy wounds ; that the
ideal is asepsis, sterilization, and non-irritant liquids ; that over-
draining and excessive flashing are both needless and harmful.
May not the time be near when the qaestion of ligation of arteries
and approximation of tissue by foreign materials will be solved
by discarding generally all except such as are provided by the
living economy ?

The successful utilization of the autogenous ligature, or suture,
depends chiefly on rigorous asepsis. It has no {>lace in a foul
infected wound. Those operations in which it is employed are
necessarily rendered more tedious, as effective technique entails
very delicate manipulation. In all cases of homologous ligation
of the blood-vessels, one should be assured that all hemorrhage is
subdued before the wound is Anally sealed. The parts must be
extremely quiescent for the first twenty-four hours. After that,
with ordinary care, everything will go on well, and, as a rule, not
more than one dressing is necessary until union is complete.



WHAT KILLS PATIENTS AFTER LAPARATOMY —
ANESTHETIC, NEPHRITIS, OR INFECTION ?

Bt F. BYRON ROBINSON, Chicago, III. «

Fob some time I have Watched the effect of the anesthetic, kidney
trouble, and infection following abdominal sections. The subject
well repays careful study. In 1885, 1 gave ether to a perfectly
healthy girl of about twenty years of age for one hour and a half. No
trace of previous ill-health could be found in her life. The ether
was given to extract sixteen teeth. Immediately after the admin-
istration of the ether, — t. e., a few weeks, she was taken ill. I found
that she had nephritis and albumin in the urine, which increased
for some months, and lasted almost a full year. I noticed that it
followed the anesthetic, and since have observed nephritis in other
cases following anesthetics and laparatomy. Now, it seems to me
that there can be but little doubt that nephritis is a frequent sequel
to ether administrations. The nephritis follows a few months
after, or, rather, it is detected a few months after by examining the
urine and finding albumin in it. Ether affects the kidney, occa-
sionally, detrimentally. But this may be on account of the fact
that the kidney is already considerably diseased, and that the
anesthetic simply precipitates matters. It may excite the old



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kobinson: what kills patients after laparatomt? 273

kidney disease, or irritate the remaining portion of the kidney
intact. At any rate, ether anesthesia is liable to induce disease of
the kidney. Chloroform is so effective on the heart, and I have had
so many narrow escapes from death that I almost entirely discard
chloroform in laparatomy. In England, either the patient or the
chloroform seem to act safer, for in large numbers of anesthesias
I never saw any trouble, but it does not act so safe in this
country.

The next subject is nephritis after laparatomy. Few lapar-
atomists seem to give much attention to the kidney in their work.
Many neglect to prepare the kidney for the ordeal of the opera-
tion. But one thing is certain : that abdominal tumors soon
induce diseases of the kidney. Doran found in autopsies of
women who died from ovarian tumors, or immediately after lapar-
atomy to remove the tumor, that the kidney presented morbid
symptoms in some eighty per cent, of the cases. Eighty per cent,
of complicating disease is a factor too large to be accidental. It
is common, in my own practice, in observing women with tumors,
to see kidney disease accompanying them. In most cases the
urine is scant and high colored, with pink urates. There is a
frequent variation in the quantity. Occasionally the urine will
be profuse in quantity and clear ; but generally scant urine of
high color is voided by women with tumors. Again, if one will
take pains to examine the urine of women possessing an abdom-
inal tumor, he will find that the urea varies very much.

In a series of cases of laparatomy at the Woman's Hospital of
Chicago, I had the urine carefully examined for urea, and it was
found varying from four to eleven grains to the ounce. After
lying in bed for a few days, the urea would average about seven
grains to the ounce — an amount which I consider safe for abdom-
inal section. Kidney disease coexisting with abdominal tumors is no
accident or incident. It is a pathological factor of importance. I
have noted it for some time ; but it must not be considered that
the kidneys alone suffer from abdominal tumors. Every abdom-
inal and thoracic organ is more or less a sufferer. The heart first
becomes hypertrophied and then ends in a degree of fatty degen-
eration. The liver suffers hypertrophy and fatty degeneration.
The causes of visceral derangement from abdominal tumors is reflex.
Pressure, producing chiefly obstruction of ducts, is another factor
of less activity. The irritation produced by the tumor is carried
to the abdominal brain by the hypogastric and ovarian plexus, or



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274 ROBINSON: WHAT KILLS PATIENTS AFTSB LA PAR ATOMY ?

anj adjacent flexes which may be irritated. In the abdominal
brain the irritation is re-organized and emitted to every viscas, and
especially severely emitted to viscera containing large nerve flexes.
So far as I can make out in carefully dissected bodies, the kidney
is sapplied with the largest nerve flexes of any organ, except the
uterus ; hence, the effect of reflex irritation on the kidney from a
tumor is very severe. The reflexes go on night and day. Summer
and Winter, with irregular constancy. The effect on the kidney
may be stated to be of three kinds : (a) The secretion of urine is
made excessive ; {b) it is made deficient, and (c) it is made dispro-
portionate. Disproportional secretion is the most disastrous.
If the kidney is continually irritated, and, consequently, its secre-
tions unbalanced, it will finally become diseased in structure. It
will end in tubular nephritis or interstitial nephritis. If pressure
of the ureters plays thero/e, obstruction of urine follows. Obstruc-
tion, reflex irritation, and congestion is frequently followed up by
infection in the kidney, the disease travels up the ureter, the
kidney pelvis becomes dilated, the kidney atrophies. Uterine
myomas are very productive of kidney disease, no jdoubt, because
they produce much friction, irritation, and reflex action. It may
be observed that the connection of the kidney to the genital
organs is very intimate. The kidney and genitals all developed
out of the Woelfian body ; hence, they are connected by
nerves and vessels. Disturbance in the genitals soon disturbs the
kidney, and kidney disease may induce genital disease. Again, it
may be observed that the peritoneum is very intimately associated
with the genitals and kidney, and injury to the peritoneum may
be followed by kidney disease. I have seen a uterus removed per
vaginum and the patient die five or six days after from nephritis.
The test-tube was two-thirds full of albumen on the application of
heat. The genitals, peritoneum, and kidney are a triumvirate with
close and intimate connections, both anatomically and physiologi-
cally. The disease of viscera which results from tumors, especi-
ally kidney disease, will demand more and more attention from
gynecologists.

Women frequently die after laparatomy from nephritis, induced
by the reflex irritation from the operation. The anesthetic may
aid in producing the nephritis if it be ether. Chloroform affects
the heart. In operating on any patient, the standard measure
should be the amount of urea to the ounce of urine. There should
not be less than six grains of urea to the ounce of urine. The



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CL1.BK : LARTNOEAL TUBERCULOSIS. 2*75

patient should lie down for several days before the operation, so
that the kidney would be well prepared for the shock.

In regard to infection causing death, it is so well recognized
that little need be said. In the past eighteen months I have lost
only one case from peritonitis after laparatomy. We have learned
to keep out peritonitis by oleanliness — by heat and water.

I would also add that much manipulation in the peritoneum
abrades the epithelium of the peritoneum, and leaves wounded
surfaces, which allow infection to get in the system easily. But
as we have no measure, constitutionally, of resistance, so we have
no measure against the susceptibility of a person to peritonitis.
However, these few desultory remarks may call attention to the
subjects of anesthesia, kidney disease, reflexes, and infection fol-
lowing laparatomy. It is hoped that some of the points may lead
others to investigate each or every individual factor.

84 Washington Street.



LARYNGEAL TUBERCULOSIS—A TYPICAL CASE WITH
ILLUSTRATION.^

Bt HORACE CLARK, M. D., of Buffalo.

This photogravure^ was made from a drawing of a throat which
presented the following essential appearances : buccal and pharyn-
geal membrane pale; otherwise nothing remarkable about these
parts. Epiglottis thin and pale. Interior of larynx pale ; secre-
tion scanty ; left ventricular band considerably swollen, partially
obscuring the vocal cord on that side ; several small yellowish
points scattered along the free margin of the left cord ; also exten-
sive ulceration upon this cord ; the right cord is thin and appar-
ently free from disease. Both arytenoids are swollen ; the swell-
ing is semi-opaque, and extends throughout the whole length of
the ary-epiglottic ligaments ; symmetrically upon these ligaments
are numerous yellowish white points ; there are two cone-shaped
elevations of unequal size in the inter-arytenoidal space ; the smal-
ler is in the median line and is truncated, with jagged upper edge,
in comparison with the larger, which is intact and lies to the left ;
confluent ulceration, of ill-defined, irregular outline, occupies the
remainder of this space to the right.

L From casen reported to the Section on Surgery, Buffalo Academy of Medicine, May
ao. 1808.

S. Page 970.



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276 clabk: laryngeal tuberculosis.

The case is taken from my clinic records for May, 1893.
Woman, thirty-one years old and married ; four living, healthy
children ; one child died in infancy of consumption ; clear heredi-
tary and personal phthisical history. Three weeks previous to
visit, throat felt as if it were " growing up ;" at this time noticed
pain in the throat, which was pretty constant, increasing daily,
and aggravated upon swallowing.

There are phthisical cavities in the upper parts of both lungs.

This history, in conjunction with the result of physical examina-
tion, belongs with the largest figures in the statistics of the disease,
with the exception of sex.



LARYNGEAL TUBERCULOSIS.-CLABK

Three facts are herein illustrated :

1. Regional origin. Development and its bearing upon diag-
nosis from syphilis.

2. Difficult and painful swallowing as the most prominent
symptom.

3. The best method of treatment.

1. The disease usually (a) begins in the posterior commissure,
in front of the arytenoid cartilages, working its way outwards
through the sub-mucosa, thence extending symmetrically to the
ary-epiglottic folds. This symmetrical arrangement of the ulcera-
tion and tumefaction is a very important factor in the {b) differen-
tial diagnosis from syphilis. In syphilis the ulcers are most fre-
quently unilateral^ single^ and large; in tuberculosis they are
bilateral^ numerous^ and small ; in syphilis the ulcers are sur-
rounded by an inflammatory zone; in tuberculosis their margin is



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clabk: laryngeal tuberculosis. 277

pcUe. If the epiglottis is the seat of ulceration, syphilis seems to
have a predilection for its upper surface 2Lnd free margin ; whereas
the ulceration of tuberculosis is lower down and at its base. In
syphilis the thickening is irregular ; in tuberculosis it is smoother
and more uniform.

2. It is such a picture as this, or one closely allied to it, which
18 most commonly seen when the phthisical patient comes for
assistance with the first symptom which he is sure relates to his
throat. This refers to difficult and painful swallowing. Hereto-
fore there may have been a noticeable increase in the cough, and
in the amount of expectoration, accompanied, perhaps, with an
exacerbation in the general decline. All this the patient has
related to his lungs. Difficult and even painful swallowing may
very well occur before the epiglottis is involved.

The epiglottis is usually represented in the books as greatly
swollen. Within two months from the date of the first visit, the
epiglottis in this case would have measured half an inch across its
upper border. More extensively ulcerated areas are also shown.
Anyone familiar with such cases could not fail to make a diagnosis
at any stage of the disease. The appearances shown in this pic-
ture could scarcely be mistaken by the learner.

8. It is at about this stage of tubercular laryngitis, when the
best results are obtained from operative procedure for the relief
of the distressing symptoms, or, indeed, for the arrest of the dis-
ease. Operation consists in the liberal use of the curette upon the
ulcerated surfaces.^ This is followed by the rubbing in of lactic
acid, in solution varying in strength from 20 per cent, to 80 per cent.,
according to the choice of the operator. The result is the forma-
tion of cicatricial tissue.* Schmidt' devised a set of knives, for
the purpose of incising the swollen parts, particularly the ary-
epiglottic ligaments. .Other observers find these enlargements to
be hard, rather than soft and edematous. The knife does not give
the result which would be expected from scoring a true edema.
The explanation is, that an appearance of edema is caused, in



Online LibraryJ. A. (Joel Asaph) AllenBuffalo medical journal → online text (page 28 of 78)